The Family Intervention Program for Dual Disorders

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The Family Intervention Program for Dual
Disorders

• Kim T. Mueser, Ph.D.
• NH-Dartmouth Psychiatric Research Center
• Main Building, 105 Pleasant St.
• Concord, NH 03301
• Telephone [phone]
• FAX [phone]
• Email kim.t.mueser_at_dartmouth.edu

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WHY IS FAMILY WORK WITH DUAL DISORDERS IMPORTANT ?

• Many DD clients have contact with family members
  who provide support and assistance
• Caregiving burden is increased when clients have
  a dual diagnosis
• Loss of family support is a major contributor to
  housing instability and homelessness in DD
  clients

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• Relatives may unintentionally encourage substance
  abuse in DD clients
• DD clients and their relatives often know little
  about mental illness and substance abuse
  interactions
• Family intervention is effective for both
  disorders

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Combined Results of Family Intervention Programs
on 2-year Cumulative Relapse Rates in
Schizophrenia (11 Studies)
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GOALS OF FAMILY INTERVENTION FOR DD

• Educate family members about mental illness,
  substance abuse, and their treatment
• Increase coping skills for all family members
• Increase social support
• Decrease burden of care on family members
• Decrease stress on clients
• Decrease substance use
• Improve client functioning
• Decrease hospitalization and homelessness

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CORE INGREDIENTS OF FAMILY WORK FOR DD

• Develop a collaborative relationship with the
  family
• Dont push the substance abuse issue before
  family is engaged
• Educate families about mental illness, treatment
  principles, and substance abuse

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CORE INGREDIENTS (continued)

• Improve communication and problem solving in the
  family
• Decrease substance abuse and its effects on the
  family
• Encourage the development of all family members
• Hang in there for the long haul

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STAGES OF TREATMENT

• Engagement, persuasion, active treatment, relapse
  prevention
• Treatment geared to motivation of family
• Different goals for each stage of treatment
• Multiple treatment options at each stage

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STAGES OF FAMILY TREATMENT

• Stage
• Engagement
• Description
• Family does not have regular contact with a
  clinician
• Goal
• To establish regular contacts with the family
  and develop a therapeutic relationship

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EXAMPLES OF ENGAGEMENT STRATAGIES

• Meeting families on their own turf (e.g., at
  home)
• Empathic listening and support
• Instilling hope that change is possible
• Educating family members about psychiatric
  illness and its management
• Helping resolve a pressing problem

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STAGES OF FAMILY TREATMENT

• Stage
• Persuasion
• Description
• Family has regular contact with a clinician,
  but client does not view substance abuse as a
  problem
• Goal
• To persuade family members that substance
  abuse is a problem and needs to be addressed

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EXAMPLES OF PERSUASION STRATAGIES

• Educate family about effects of substance abuse
  on mental illness
• Encourage family members to develop external
  social supports
• Begin problem-solving on family issues that may
  or may not be related to substance abuse
• Explore how substance abuse may interfere with
  achieving client or other family goals

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STAGES OF FAMILY TREATMENT

• Stage
• Active treatment
• Description
• The client views substance abuse as a problem
  and is motivated to work on reducing substance
  use
• Goal
• To help family members develop strategies for
  reducing substance abuse

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EXAMPLES OF CLINICAL STRATAGIES

• Modify stressful communication styles that may
  contribute to substance abuse
• Teach problem solving skills to help client
• Refuse offers to use substances
• Avoid high risk situations
• Develop alternative leisure activities
• Cope with persistent symptoms
• Structure daily time
• Teach family how to set limits

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STAGES OF FAMILY TREATMENT

• Stage
• Relapse prevention
• Description
• The clients substance abuse is in
• remission
• Goal
• To develop relapse prevention strategies
• and expand recovery to other areas
• of functioning

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EXAMPLES OF CLINICAL STRATAGIES

• Develop a relapse prevention plan
• Use problem solving to address
• Health (e.g., smoking, weight, exercise)
• Social relationships
• Independent living
• Work
• Leisure time
• Address other family related goals

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OVERVIEW OF INTERVENTION

• Two treatment modalities
• Behavioral Family Therapy (BFT) (time-limited)
• Multiple family groups (time-unlimited)
• BFT for psychoeducation, communication skills,
  problem solving skills
• Multiple family groups for additional psycho-
  education and social support
• BFT precedes multiple family groups
• Clients and relatives involved in all sessions

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GOALS OF BFT

• To establish a working alliance between the
  treatment team and family
• To provide education to family members about
  mental illness, substance abuse, and the their
  treatment
• To enhance family coping through
• Improved communication
• Teaching problem solving skills

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FORMAT OF BFT

• Individual family sessions
• Relatives and clients included
• Open door policy for reluctant participants
• One hour sessions
• Sessions conducted on a declining contact basis
• Treatment is long-term, not short-term
• Focus is on learning new information and skills,
  not fostering insight

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Phases of BFT

• Phase Sessions
• Connecting 1-3
• Assessment 2-4
• Psychoeducation 4-6
• Communication skills 1-6
• Problem solving 5-15
• Termination 1

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ENGAGING THE FAMILY

• Be respectful, non-judgmental, empathic
• Explain you want to help family members become
  members of the treatment team
• Describe goals of family program as education,
  reducing hospitalizations, and helping client
  independence
• Allow relatives to vent and tell their story

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ASSESSMENT OF THE FAMILY

• For Each Family Member
• What do they understand about the disorders?
• What are their short-term goals?
• What are their long-term goals?
• What interferes with obtaining their goals?
• For the Family as a Unit
• What are their strengths?
• What problems do they have in communication?
• How do they solve problems together?

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PRINCIPLES OF PSYCHOEDUCATION

• Education is interactive
• Use multiple teaching aids
• Connote client as the expert
• Elicit relatives experience and understanding
• Avoid conflict and confrontation
• Education is a long-term process
• Evaluate understanding
• Review materials as often as possible

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EDUCATIONAL TOPICS

• Psychiatric diagnosis
• Medications
• Stress-vulnerability model
• Role of the family
• Basic facts about alcohol drugs
• Alcohol drugs Motives consequences
• Alcohol drugs Treatment
• Infectious diseases
• Communication skills

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EDUCATION PSYCHIATRIC DISORDER

• Client as the expert
• Dispelling myths
• Symptoms
• Establishing diagnosis
• Course and outcome

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EDUCATION MEDICATION

• Names
• Side effects
• Clinical effects
• Symptoms
• Relapse
• Nonaddictive nature
• Biological theories
• Effects of alcohol and drugs

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EDUCATION STRESS-VULNERABLILITY MODEL

• Disorder is caused by biological factors and
  environmental stress
• Coping can mediate noxious effects of stress
• Psychiatric disorders can be improved
• Medications
• Reducing substance abuse
• Reducing environmental stress
• Enhancing patient and relative coping

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EDUCATION ROLE OF THE FAMILY

• Recognition of early warning signs
• Effect of mental illness on the family
• The family system
• How the family can support treatment

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EDUCATION EFFECTS OF DRUGS AND ALCOHOL

• Substance types
• Effects of substances positive and negative
• Motives for using substances
• Consequences of substance use abuse and
  dependence
• Reasons for substance use problems
• Treatment options for substance use

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EDUCATION INFECTIOUS DISEASES

• HIV, Hepatitis B C
• Routes of transmission
• Health consequences
• Avoiding contracting diseases
• Avoiding spreading diseases
• Treatment

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COMMUNICATION SKILLS

• Communication and mental illness
• Improving communication
• Get to the point
• Keep communications focused
• Speak clearly
• Use feeling statements
• Speak only for yourself
• Focus on behavior

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OTHER COMMUNICATION SKILLS

• Non Verbal
• Facial expression
• Eye contact
• Body orientation
• Posture and gestures
• Paralinguistic
• Voice tone
• Loudness

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COMMUNICATION PROBLEMS THAT WARRANT SKILLS
TRAINING

• Frequent fights
• Pejorative put-downs
• Snide, sarcastic, caustic comments
• Lack of verbal reinforcement between members
• Difficulty being specific when talking about
  feelings and behavior

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COMMUNICATION SKILLS

• Active listening
• Expressing positive feelings
• Making positive requests
• Expressing negative feelings
• Compromise and negotiation
• Requesting a time-out

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STEPS OF SOCIAL SKILLS TRAINING WITH FAMILIES

• 1. Establish a rationale for the skill
• 2. Present the component steps of
• the skill
• 3. Model (demonstrate) the skill
• 4. Engage a family member in a role
• play to practice the skill
• 5. Provide positive feedback about the
• role play

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• 6. Provide corrective feedback
• 7. Engage the family member in another role
  play
• 8. Provide additional feedback
• 9. Engage other family members in
• role plays, followed by feedback
• 10. Assign homework to practice the
• skill

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PROBLEM SOLVING

• 1. Define the problem
• 2. Brainstorm solutions
• 3. Evaluate solutions
• 4. Choose best solution(s)
• 5. Plan on how to implement
• solution
• 6. Follow up plan

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FORMAT OF PROBLEM SOLVING

• Chairman leads family through steps of problem
  solving
• Secretary records problems solving efforts
• Focus is on getting all members input AND
  sticking to steps of problem solving
• If at first you dont succeed, problem solve
  again
• Always schedule a follow-up meeting

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EXAMPLES OF TOPICS FOR FAMILY PROBLEM-SOLVING

• Identifying alternative social outlets
• Responding to offers to use substances
• Determining strategies for dealing with
  persistent symptoms
• Exploring alternative recreational activities
• Finding work or other meaningful activities

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FORMAT OF PROBLEM-SOLVING TRAINING

• Rationale for problem solving
• Review steps of problem solving
• Selection of problem to work on
• Demonstration of problem solving with therapist
  as chairman
• Homework assigned to family to implement solution
  have follow-up meeting

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• At next meeting, results of family meeting
  reviewed, more work on problem if needed
• Work on new problem with family members taking
  roles of chairman secretary
• Therapist focuses mainly on teaching problem
  solving skills to family
• Family solves problems on their own

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• Homework assignments given to practice
  progressively larger parts of problem solving
• Easier problems tackled first
• Problems selected based on family goals,
  individual members goals,
• observations by therapist

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PROBLEM SOLVING AT DIFFERENT STAGES OF TREATMENT

• Engagement
• Persuasion
• Active treatment
• Relapse Prevention

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• Engagement
• Problem solving done only to respond to crises
• Therapist leads problem solving
• Solving the problem is paramount, not teaching
  skills

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• Persuasion
• Problem solve to reduce effects of substance
  abuse of family
• Problem solve to reduce effects of substance
  abuse on client
• Address other members goals
• Use motivational interviewing to address client
  goals not directly related to substance abuse,
  aiming to develop discrepancy

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• Active Treatment
• Address high risk situations
• Coping strategies for symptoms, cravings
• Alternative socialization outlets
• Creating structure and new meaning in life
• Self-help

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• Relapse Prevention
• Developing relapse prevention plans
• Improving quality of life
• Health
• Social relationships
• Work, school
• Parenting

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WHEN TO TERMINATE BFT

• Decision made by therapist and family
• Client has achieve 6-12 months sobriety
• Maximum treatment gains appear to have been made

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TERMINATION

• Goals
• To bring closure to the end BFT and plan for how
  family can maintain contact with treatment team
• Strategies
• Reviewing past accomplishments of family work
• Anticipate possible stresses and strategies for
  coping with them
• Review the relapse prevention plans

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MULITPLE FAMILY SUPPORT GROUPS

• Co-led by professionals
• Meet monthly for 1-2 hours
• Time unlimited
• Include 3-15 families, clients and relatives
• Provide both education support

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WITHIN SESSION STRUCTURE OF MULITPLE FAMILY GROUPS

• 1. Introductions, sharing (5-10 min.)
• 2. Presentation of educational
• material, either by group leader
• or invited speaker (30-45 min.)
• 3. Group discussion (30-45 min.)
• 4. Closing comments, wrap-up (5-10 min.)

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ADDITIONAL FEATURES OF MULTIPLE FAMILY GROUPS

• Leaders are members of treatment teams
• Cross-family communication
• Leaders are educators and facilitators
• Leaders are available outside session for
  consultation

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• Topics selected by leaders and families
• Group problem solving occasionally done
• Facilitation of sharing coping strategies
• Reminder letters sent out
• Refreshments served
• Celebrations observed

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EXAMPLES OF TOPICS FOR MULITPLE FAMILY GROUPS

• Symptoms of mental illness
• Medications
• Coping with depression
• Managing stress
• Setting limits
• Vocational rehabilitation
• Planning for the future

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• Advances in research
• Effective communication
• Improving leisure time
• Addiction
• Self-help groups
• Dealing with anxiety
• Recovery
• Relapse prevention planning
• Increasing client independence
• Siblings