A Position Paper Of The Family Committee Of The Pennsylvania Psychiatric Leadership Council For Use In The Centers of Excellence - 11/3/09
Ellen Berman, MD; Kathleen Cantwell, BSW; Edie Mannion, MFT
PREAMBLE
In writing this document, we are making two assumptions: 1. Fellows will enter with widely varied attitudes, knowledge and skills in working with families, and 2.There are financial, political and systemic barriers in community agencies that challenge routine work with family members of individuals. Therefore, if Fellows have not, during their residencies, obtained the knowledge, attitudes and skills described in this document, the Fellowship program will need to develop ways for the Fellows to obtain these competencies. During their Fellowship, further arrangements should be made for activities and experiences that will help Fellows understand the financial, political and systemic issues that have impeded routine family inclusion in psychiatric care for adults, so that they are in a strong position to become leaders in reducing these barriers at local, state and federal levels.
OUR MANDATE
For people in recovery from psychiatric disabilities, the development and maintenance of family/significant supports is critical to sustaining a functional life. While not all individuals have available families, the majority have some important connection to significant people who can affect their recovery in more positive ways if given support, information or other appropriate assistance. Involved families and other significant people may at times be problematic, but they provide a way for the person to be part of the relational world. Whether they live with the person or not, they are often aware of their relative’s evolving health or illness, serve as a potential early warning system for relapse, support treatment compliance, and carry the burden of dealing with setbacks and emergency care.
The principles of Recovery, and of responsible psychiatric care, mandate that whenever possible families should be engaged in collaborating with the treatment in some way, and offered support for their wellbeing and needs as caregivers. Unfortunately, the behavioral health system in this country has consistently marginalized families. Lack of training, lack of time and lack of financial supports for family care have allowed us to ignore the body of research providing strong evidence that family involvement improves recovery, decreases relapse and sharply decreases re-hospitalization. In the meantime, options for hospitalization and respite care have greatly decreased, and families are left shouldering most of the responsibilities of care and recovery. This family curriculum for community psychiatry Fellows is geared to creating leaders who understand the needs of families and the issues of larger systems, and are skilled enough to advocate for family inclusive care at their facilities. This requires that they have had enough experience with families to understand the issues for which they are advocating. Beyond curriculum, the Fellowship must model family involvement within its teaching and practice sites. The best curriculum will be useless if the leadership of the program does not model the relevance of family inclusion. The community psychiatrist must see families as partners in treatment and have knowledge of and some experience with all types of family care. They should be familiar enough with systems theory to use these concepts in treatment, and to be able to assume a leadership role in the wider community systems. An understanding of complex social systems is critical for operating in the public sector.
THE CURRICULUM
Limits of Curriculum
This curriculum is geared to adult families; that is, families where both the individual and caregivers are late adolescents or adults. In this paper “family” is defined as a group of connected people bound by ties of obligation and affection, generally biological or legal kin but often including other significant people who can affect recovery in positive and/or negative ways. While there may be dependent children in the families, they are not designated as the primary individual. Family work in the context of child psychiatry requires additional skill sets and supports. However, since non-symptomatic children with ill parents may need support and education, several relevant resources are noted in the bibliography section of this document. This curriculum is not designed to produce experienced family therapists. Family therapy is seen as only one of many potential family inclusive interventions, and can be delivered by a variety of trained persons.
Scope and Nature of Potential Family Interventions
Family intervention may take many forms. From least to most intensive, they include:
• The basic family interview (assessment, check-in) to gather information and answer questions. This may be done with or without the individual present.
• Family consultation, focused on the family’s needs and questions, to determine the appropriate type of help. This is commonly done without the individual present.
• Family education, either individually or in family workshops, which usually does not include the individual with the illness.
• Family support groups for peer support.
• Psychoeducation, which includes the individual and family members, either one-to-one or in multi-family group format.
• Couples or Family therapy, if necessary and agreed upon by all parties, preferably done by therapists with knowledge of the individual’s specific disorder.
The majority of families want access to health care providers, basic information on how to help their loved ones and reduce their own caregiver burden, and guidelines about the causes and course of the illness, the prognosis and the treatment plan. Family therapy should not be assumed to be the first or most common intervention, but should be available if appropriate and agreed to by all concerned. It is best done by a family therapist with expertise in treating the relative’s particular disorder. While individuals may initially reject the idea of any form of family involvement, it is important for therapists to explain the benefits of family collaboration and return to the issue periodically.
COMPETENCIES NEEDED
Specifically, the Fellow must have the following Attitudes, Knowledge and Skills regarding families:
Attitudes
1. Demonstrate empathy, interest in, respect for all family members, and balanced concern for multiple points of view. The Fellow must accept differences in perspectives on the problem and solutions as normal, and potentially useful phenomena.
2. Work collaboratively with families and see them as allies, assessing their strength and resilience as well as difficulties.
3. Understand the meanings of psychiatric illness for individuals and families, including issues of stigma. We would hope that Fellows would work to reduce stigma by speaking appropriately, publicly or privately, if they have had a personal experience with psychiatric illness.
4. Acknowledge realistic limitations while maintaining an attitude of hopefulness. Show patience and willingness to take a long term perspective. Understand that the process of illness and recovery is nonlinear and takes time, and those family members, and therapists may be at different points in the process.
5. Openness to models of treatment that are not limited to the medical model, but integrate recovery, psychiatric rehabilitation, and community integration.
Knowledge
The Fellow is expected to demonstrate knowledge of family factors as they relate to psychiatric and medical disorders, based on scientific literature and accepted standards of practice. The Fellow is expected to demonstrate knowledge of the following:
1. Basic concepts of systems theory, applicable to families, multidisciplinary teams in clinical settings, and medical/government organizations impacting the individual and doctor.
2. Principles of adaptive and maladaptive relational functioning in family life; family organization, communication, problem solving, emotional regulation and resilience.
3. Normal couple and family development over the life cycle and the importance of multi-generational patterns.
4. The interrelationship between specific psychiatric disorders and family dynamics, and how these interrelationships change throughout the family life cycle. In particular, this includes understanding of the grieving process in families who are newly introduced to diagnosis, and in families where there is long term illness, subjective and objective burdens of different family subsystems (parents, siblings, spouses, and children), issues of strength and gratification derived from caregiving, and issues of stigma for both the individual and family members.
5. Factors of age, gender, class, culture and spirituality that affect family functioning.
6. The variety of family forms (single parent, stepfamily, same-sex parents, etc).
7. Special issues in family life including divorce and remarriage, family member loss from death or ambiguous loss, immigration, illness, sexuality, secrets, affairs, violence, alcohol and substance abuse.
8. Ways of supporting and developing the parenting skills of the individual, and appropriately providing their children with education and support without pathologizing them.
9. Trauma connected to illness related events, e.g. violence, victimization, disappearance of a family member, iatrogenic events (treatment-caused problems).
10. Legal and emotional issues regarding confidentiality when dealing with family members.
11. The place of peer/family resources such as national and local support groups, on-line support groups, etc. in supporting those in recovery and their families.
12. Relationship of families to larger systems, e.g. schools, work, health care systems, government agencies. An appreciation for the differences in types of interventions to determine what is best for a particular family and community setting.
Skills
1. Effectively negotiate with individuals with illness about whom to include in their treatment and recovery process, while following HIPPA and state confidentiality laws and procedures. Effectively invite family members to collaborate, keeping appropriate confidentiality. Connect appropriately with others in the individual’s social support circle and service providers.
2. Demonstrate the ability to conduct a family interview, and complete an assessment and formulation that includes family factors. Operational family interview skills include:
a. Meet with significant family members. Be able to present a rationale to individuals and family members to include families in the recovery process, especially when they are unsure about the process or have a history of difficult relationships with previous mental health providers.
b. Negotiate effectively with the individual about whom to involve in their care and what information can be discussed, balancing the need for family involvement with appropriate confidentiality.
c. Foster a therapeutic alliance with all family members by instilling feelings of trust, openness and rapport. If appropriate, consider the uses of appropriate and relevant self-disclosure to build trust and respect if one has had mental illness in one’s own family.
d. Gather an appropriate history of both the individual and the family, as well as an understanding of current difficulties, family dynamics, and current strengths and resources.
e. Develop a description of the issues, or formulation if appropriate, that can be conveyed to the individual and family and used as a basis for treatment planning.
3. Develop a plan for family connection to resources or services, both professional and peer, in the community. This plan might include anything from occasional check-ins, to support groups, to family therapy.
4. Conduct a family education workshop and consultation. Conduct or participate in a family psychoeducational group or workshop.
5. Be familiar with family therapy techniques, enough to refer appropriately. This should include some experience in the use of basic family therapy skills, such as teaching problem solving and communications techniques that are helpful in families with an ill family member.
6. Consider and learn to use, when appropriate, alternatives to standard office meetings. For example, phone sessions and videoconferencing are becoming more commonly used strategies when families have transportation issues, and home visits, when possible, are a helpful window into the individual and the family’s context.
Training Requirements
Basic knowledge of family issues requires a significant amount of didactic coursework (usually the equivalent of a full year course, 30 hours, taught at varying points during the residency years). If the Fellow has not had appropriate training to cover these knowledge domains, the Fellowship must find some way to continue their education, whether by offering coursework, enrolling the fellow in coursework given in another area of the residency, or arranging for independent study with an appropriate supervisor. Fellow supervision should regularly include review of family-systems inclusion and the plan for family connection to treatment. This could be accomplished either through general case conference or a separate forum devoted to cases with complex family inclusion issues.Attitude and skill development is contingent on observing and doing family interviews and integrating family work into daily practice. During the Fellowship it is recommended that the Fellow be able to:
1. Demonstrate a consistent pattern of concern and support for family members of individuals in all training settings.
2. Observe family interviews designed for support, education or change.
3. Facilitate at least one family education or psychoeducation group, either with supervision or as a co-facilitator.
4. Have specific contact and involvement with affiliates of national support and advocacy groups such as National Alliance on Mental Illness, National Mental Health Association, Depression and Bipolar Association, or local groups.
5. If they cannot demonstrate that they have already done so, the fellow should treat at least two couples and two families with family therapy under supervision, in order to understand the philosophy and techniques available, with the goal of making appropriate referrals.
Competency Assessment
These attitudes, knowledge and skills should be measured using the residency program’s standard methods. For sample competency screening methods, see the Berman and Heru article in Family Process, below.
BIBLIOGRAPHY
This bibliography is in no way comprehensive. It includes articles which are general reviews of issues, examples of ways to create systems change, and training methods. Each of the articles contains excellent and fully developed reference lists.
RESEARCH
• Heru, A. Family Psychiatry: From Research to Practice. American Journal of Psychiatry, 2006, Vol.163:6, Pages 962-968.
TRAINING
• Berman, E, Heru, A. Family Systems Training in Psychiatric Residencies. Family Process, 2005, Vol. 4:3; Pages 321-335
• Berman, E et al (Group for the Advancement of Psychiatry Committee on the Family). Family-Oriented Patient Care through the Residency Training cycle. Academic Psychiatry, 2008, Vol. 32:2, Pages 111-119
• Heru, A. and Drury, L. Overcoming Barriers in Working with Families. Academic Psychiatry, 2006. Vol. 30, Pages 379-384
• Rait, D., Glick, I. Reintergrating Family Therapy Training in Psychiatric Programs: Making the Case. Academic Psychiatry, 2008, Vol. 32:2, Pages 76-80
• Rait, D., Glick, I. A Model for Reintegrating Couples and Family Training in Psychiatric Residency Programs. Academic Psychiatry, 2008, Vol. 32:2, Pages 81-86
CLINICAL FAMILY CARE IN COMMUNITY SETTINGS
• Cohen, A, et al. The Family Forum: Directions for the Implementation of Family Psychoeducation for Severe Mental Illness. Psychiatric Services, 2008: Vol. 59:1, Pages 40-48.
• Corrigan, P., Mueser, K., Bond, G., Drake, R., Solomon, P. Principles and Practice of Psychiatric Rehabilitation, New York, The Guilford Press, 2008 , note esp. Chapter 11: Family Interventions, P. 234-262. We recommend this entire book.
• Gopfert, M., Webster, J., Seeman, M. Parental Psychiatric Disorder: Distressed Parents and Their Families. Cambridge University Press, UK, 2004, 2nd edition.
• Grunebaum, H., Friedman, H. Building Collaborative Relationships with Families of the Mentally Ill. Hospital and Community Psychiatry, 1988, Vol. 39:11, Pages 1183-1187.
• Lappin, J., VanDeusen, J. Family Therapy and the Public Sector. Journal of Family Therapy, 1994, Vol.16, Pages 79-96.
• Marshall, T., Solomon, P. Professionals' Responsibilities in Releasing Information to Families of Adults with Mental Illness. Psychiatric Services, 2003, Vol. 54, Pages 1622-1625.
• Marsh, Diane T. Serious Mental Illness and the Family: The Practioner’s Guide. NY:Wiley, 1998, note esp.Chapter 7: Family Intervention Strategies: Family Consultation.
• Sherman, Michelle D. Reaching Out to Children of Parents with Mental Illness. Social Work Today, September/October 2007, Pages 26-30.
Website, and links for children of the mentally ill:
http://www.howstat.com/comic/ (Australia)
Website for stories and guidelines for family members:
http://www.mhasp.org/coping
11/3/09
Ellen Berman, MD
Kathleen Cantwell, BSW
Edie Mannion, MFT
Phyllis Solomon, PhD