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For more information contact Dr. Glynn, Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., B151j, Los Angeles, CA 90073 (e-mail: sglynn @ucla.edu). Dr. Glynn is also with the Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles. Dr. Dixon is with the Mental Illness Research, Education and Clinical Center (MIRECC), VA Capitol Health Care Network, and the University of Maryland School of Medicine, Baltimore, where Dr. Murray-Swank was previously but who is now with the VA Eastern Colorado Healthcare System, Denver. Dr. Cohen is with VA Desert Pacific MIRECC, West Los Angeles, and the Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California, Los Angeles.
Many benefits of family participation in evidence-based interventions for persons with serious psychiatric illnesses have been reported. The American Psychiatric Association's (APA's) 2004 best-practice guidelines for treatment of schizophrenia and the Schizophrenia Patient Outcomes Research Team (PORT) 2003 treatment recommendations urge the use of family services; in addition, APA's best-practice guidelines for bipolar disorder recommend family education. Unfortunately, many efforts to implement family-based services have resulted in disappointing numbers of involved families.
Evidence-based family interventions typically include an initial engagement phase, in which the clinician, not the consumer, assumes primary responsibility for inviting relatives to join the treatment team. We have developed a brief, manualized intervention, the Family Member Provider Outreach (FMPO) program, that orients consumers and relatives to the possibility of including families in treatment and encourages consumers to invite relatives to become involved in the consumer's care. FMPO is consistent with a recovery orientation in emphasizing consumer self-direction and empowerment. It incorporates an individualized and consumer-directed approach and is grounded in the belief that in most cases consumers can and should be responsible for deciding if and how their relatives should be involved in their treatment and for inviting them to participate should this be desired. The family member provider (FMP), who facilitates the intervention, is a relative of a person with serious psychiatric illness and has mental health professional training. This dual role helps the FMP to bridge the gap between the family, the consumer, and the care team. The FMP may or may not be a member of the consumer's specific mental health treatment team.
FMPO consists of two phases offered over approximately two months. Sessions are typically offered in the clinic, but they can be offered in the home.
In phase 1 consumers are offered two to three 45-minute individual sessions with the FMP. The FMP gets to know the consumer and uses motivational interviewing techniques (open-ended questions, values clarification tasks, and decisional balances) and behavioral strategies to help the consumer make deliberative decisions about involving the family in his or her care. The consumer also practices extending an invitation to relatives to join phase 2 of the intervention, should this be the consumer's decision. Potential obstacles to involvement are discussed for resolution. Consumers end phase 1 with a decision about whether to invite family to phase 2.
In phase 2 consumers' families are offered two to three 45-minute individual sessions with the FMP to help the family connect with the consumer's treatment team. The FMP uses motivational interviewing techniques to direct the conversation and provides basic information on psychiatric illness (including facts about the illness, medication, and relapse prevention). Families receive information about contacting the treatment team and solving potential problems (such as staff unavailability and concerns abut confidentiality). Families are also provided information on local support and educational groups. The consumer may or may not be present at these sessions.
From May 2005 to April 2006, we conducted a pilot of FMPO with 17 consumers receiving treatment at the Veterans Affairs (VA) Maryland Health Care system. Their families had not had contact with the treatment team for at least six months. Informed consent was obtained from participants, and all procedures were approved by the relevant institutional review boards. The FMP was a doctoral-level clinical psychologist completing a fellowship at the VA Maryland Health Care System who had a family member with serious psychiatric illness. Seventy-five percent of the participants were male, and 70% were African American. Their mean ±SD age was 48.8±7.1. Diagnoses included 11 consumers (65%) with schizophrenia or schizoaffective disorder, four (24%) with bipolar disorder, and two (11%) with major depression.
All clinician notes were reviewed to assess whether any mental health clinician had contact with the family, in person or via telephone, and whether the family attended monthly support groups at the VA facility during the six months after the intervention. After participation in FMPO phase 1, 13 of 17 (76%) consumers invited their families into phase 2 of the program. After completing the FMPO program, 11 of 17 families (65%) had contact with the treatment team and five of 17 (29%) attended at least one monthly support group at the VA facility.
Limitations to our findings were that our sample was small; we had only one FMP facilitator, so we were unable to establish the generalizability of our results to other providers; and we had data from only the active treatment group. Nevertheless, our data suggest that the FMPO program may be a gateway to developing successful collaborations with families of persons receiving mental health care for serious psychiatric illnesses. We are now evaluating the intervention in a randomized controlled trial.
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