Between 40 to 65 percent of people with a mental illness either live with a family member or have a family member involved in the management of their mental health treatment and recovery. One VA study found that veterans with schizophrenia who had family support reported a higher quality of life, fewer hospital days, and lower health care costs. Other studies have found that the involvement of relatives in treatment decreased relapse rates from 20 to 50 percent.
These demonstrated benefits of family involvement have prompted several expert groups to recommend that family psychosocial programs be offered to every individual with schizophrenia who has on-going family contact. Ideally, families should be offered a combination of education about the illness (psychoeducation), family support and crisis intervention, and behavioral family therapy.
Psychoeducation refers to a group of programs that share certain characteristics. For example, they are usually developed and led by mental health professionals to provide information on the symptoms and treatment for a particular psychiatric disorder, and are mostly focused on client outcomes. Psychoeducational programs have a variety of formats and settings and utilize different therapeutic techniques. These programs can provide single family or multiple family groups, didactic or interactive client participation in clinic or community-based settings. Despite the success of these programs few families participate in psychoeducational programs. In fact, one study found that less than 40 percent of outpatient family members received information about groups and attended a support group and less than 50 percent of relatives of inpatient were referred to programs.
Support groups are another resource for family members of individuals with acute and chronic psychiatric problems. These groups are typically offered several times a month and may be led by peers or health care professionals. Typically, support groups are not as formal as psychoeducational programs and give family members the option to attend on an "as needed" basis. Much of the emphasis in support groups is learning from others who are coping with similar difficulties. These programs are useful for
Behavioral Family Therapy (BFT) is another type of family intervention. It is conducted with the client and his/her family members, and is typically led by a nurse, a social worker, or psychologist. The goals of BFT include thorough assessment of problems, education about mental illness, and training to teach communication and problem solving skills to address specific concerns. Techniques such as role playing and homework are often used. BFT typically lasts a minimum of nine months with weekly meetings in the beginning of treatment that taper to monthly meetings. It may be conducted in a group with several families or with a single family.
Unfortunately, there are many barriers to participation in family psychoeducational programs. Families may be unable or reluctant to travel to meeting sites or may have other scheduling or caregiving responsibilities that preclude attendance. Mental health professionals may feel they lack the expertise to conduct family interventions, or may be unable to meet evenings and weekends, when families are often more available.
To address these obstacles, Dr. Shirley M. Glynn (See "Faces of MIRECC") is evaluating the efficacy of utilizing the internet to conduct multiple family groups online for caregivers of persons with schizophrenia at the VA Greater Los Angeles Healthcare System. The intervention includes two to three chats each week hosted by mental health professionals, written materials, streaming video lectures on pertinent educational topics (e.g. relapse prevention; depression and anxiety in caregivers), a discussion board, and links to online resources. To protect participant privacy, access to the site is password protected. For further information on the program or to make a referral of someone in the greater LA area, please contact Shirley Glynn at sglynn@ucla.edu.
For more information about psychoeducational programs, support groups, or behavioral family therapy, ask your mental health care provider or see NAMI program descriptions on Page 4.
| Common Ingredients of Effective Family Intervention Programs |
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Vocational Rehabilitation: Recovery is Work - Top
by Shirley Glynn, Ph.D.
Surveys indicate that 60 to 70 percent of clients with psychiatric disorders would like to work, but few do. Many factors contribute to under-employment; including some that are due to the disorders themselves and some that are related to the social consequences of the illnesses. Positive schizophrenia symptoms, such as paranoia, may limit the person's ability to get to a job; whereas depression and anxiety might make it very difficult for individuals to tolerate any scrutiny from their supervisors and prompt them to quit their jobs. In addition, some of the cognitive difficulties that are often observed in persons with psychiatric disorders may interfere with employment. For example, attention and learning problems may make some jobs difficult to perform. Side effects of psychiatric medications, such as sedation or motor problems, may also inhibit the ability to perform some jobs.
There are also many social factors that hinder employment for individuals with psychiatric illnesses. Stigma associated with having a psychiatric disorder may result in less frequent and less positive social interactions with coworkers. The overwhelming economic consequences of having a psychiatric disorder may also limit the resources necessary to obtain employment, such as having a car for transportation. The devastating personal consequences of psychiatric disorders may limit opportunities, such as education and vocational training, which are prerequisite for many jobs.
To overcome the many barriers faced by persons with serious psychiatric illnesses in returning to the workforce, many types of training programs have been established. Pre-vocational programs, also called "train and place" models, start individuals working in a sheltered setting and then graduate them to competitive employment. These individuals appear to benefit from these programs initially, however, many never graduate to competitive employment.
Another model of vocational rehabilitation, called Individual Placement and Support (IPS), is being investigated by researchers at the VISN 22 MIRECC. Often labeled "place and train", the goal of IPS is to obtain competitive employment in the community for every individual who would like to work. By minimizing prevocational training, IPS strives to quickly move individuals into competitive jobs, i.e., minimum wage jobs that are open for anyone to apply. The IPS model carefully considers the client's motivation and preferences to direct the job search and tries to match the client's skills, strengths, personality, and degree of illness and recovery with the job. Rather than expecting the client to change to fit the job, the goal of IPS is to find a position that matches the client. Furthermore, IPS services are embedded in the mental health treatment team setting where work is considered mental health treatment. IPS is delivered by an employment specialist, a person with knowledge of both mental illness and business world, who serves as a member of the interdisciplinary treatment team. Further integration of treatment and rehabilitation is accomplished by continuing to support the client once he or she has been employed.
Studies have demonstrated that more people enrolled in the IPS model get jobs than those participating in other vocational rehabilitation models. Still, even with IPS, a substantial minority of clients with serious psychiatric illness does not get jobs and many have difficulty maintaining employment. The VISN-22 MIRECC is currently conducting an NIMH-funded trial under the direction of Dr. Stephen Marder to test an intervention to improve job tenure. In addition to IPS, some clients in the study will participate in a class that teaches more about the job itself, as wells as skills such as problem solving and appropriate socializing at work. To learn more about the study or to make referrals in the greater Los Angeles area please contact Colleen Kollar at (ckollar@ucla.edu).
Road to Recovery: Clients in the Driver's Seat - Top
The concept of recovery has recently assumed a prominent role in the care for persons with severe mental illness such as schizophrenia. By definition, recovery places the client at the center of the treatment plan, emphasizing the client's strengths and goals and increasing his or her involvement in disease management. Several types of peer support programs have evolved. These include mutual support groups, consumer-run services, and employment of consumers as providers within the clinical and rehabilitative settings.
Similar to the 12-step programs that have been developed for persons with addictions, individuals with severe mental illnesses have formed support groups. Some have been formed by clients (GROW), while others were have been started by mental health providers (Recovery, Inc.). Support groups provide nurturing social networks, guidance in negotiating everyday problems, and examples of effective role models. Research has found that those persons who regularly attend groups and who are more committed to the group have larger social networks and may experience less severe psychiatric symptoms, have few hospitalizations or shorter lengths of stay.
Consumer-run services consist of drop-in centers (clubhouses), and residential, outreach and vocational programs. These services tend to be more structured in their activities and interactions than mutual support groups. For example, relationships in consumer-run services are more likely to take a traditional, one-directional form of professional-client relationship than a mutually supporting, two-directional peer-to-peer relationship. Consumer-run services may be more accessible to minority populations than traditional mental health services.
| According to William Anthony, a leader in the field of rehabilitation, recovery is viewed as a way of living a satisfying, hopeful and contributing life and involves the development of new meaning and purpose in a person's life as that person grows beyond the catastrophic effects of mental illness. The focus on recovery has been the result of the writing of people with severe mental illnesses about their recovery process and the results of long-term outcome studies showing that people with severe mental illnesses recover over time. |
More recently, conventional clinical and rehabilitative programs have been hiring consumers as staff members. These consumer-providers can provide mentoring and role modeling, peer support and education, and assistance and counseling for everyday needs in a manner that mental health professional can not. Because the employment of consumers as providers is so new, little information is available to evaluate its effectiveness. However, a project led by VISN-22 MIRECC researcher Matthew Chinman, Ph.D., has recently begun to adapt a consumer provider intervention for veterans. Dr. Chinman, in conjunction with researchers from VISN-16, will gather information from surveys and interviews with both VA and non-VA clients, health care providers, and program managers to better understand the factors associated with the successful development and implementation of a consumer-provider treatment program to improve services to veterans with serious mental illnesses.