Since FPE is effective in preventing relapses, it may be optimal for families of patients with recent illness onset in which the patient has frequent relapses; but FPE may be less relevant in situations in which the patient has been stable for many years. For example, the needs of aging parents whose daughter with schizophrenia is living in a group home and struggling with repeated exacerbations and hospitalizations may be very different from those of a middle-aged wife whose husband has schizophrenia, but is stable with medication and treatment and is able to work and actively participate in parenting.Other considerations
For assistance with unmet needs, many families have turned to community-based, family-member led programs, such as the Family to Family Education Program (FFEP) from the National Alliance on Mental Illness (NAMI). FFEP uses unpaid volunteers and a 12-week course that combines education, skill building, and support. The focus is not on patient improvement but on improving the coping, knowledge, and well-being of the caregiver. Preliminary evidence suggests that FFEP reduces family members' subjective illness burden and increases empowerment.20,41
A randomized trial of the Journey of Hope program, which is similar to FFEP, found that participants endorsed fewer depressive symptoms and had greater vitality and improved views of their relatives with mental illness.42 Programs such as these have the potential not only to improve family members' well-being but also to educate them about mental illness and its treatment and how to better navigate the mental health system.
New approaches aim to engage patients and families using motivational techniques, support, and problem solving to identify and address unmet needs and preferences. The Family Member Provider Outreach program, a recovery-oriented brief, manualized approach, is being tested to see if it overcomes barriers to family involvement in care and FPE.43Working with families is good clinical practice
Good clinical practice suggests that clinicians talk with patients and their families about what they want and need and provide them with a flexible menu of interventions, including FPE and NAMI programs, such as FFEP. Families typically value the mental health services provided to their ill relatives but may have minimal knowledge about psychiatric illness and available resources, as well as inadequate supports and limited training in the development of coping and problem-solving strategies.5 Dialogue with families requires a combination of the clinical skills needed to work with patients and the communication skills necessary for interacting effectively with colleagues.44
The challenge of providing the right intervention at the right time for each patient-family unit is daunting, and research has yet to provide clear evidence for developing a set of guidelines for family interventions that are feasible, well-accepted, and effective. Clinicians working in inpatient settings need to remember that families are typically dealing with a crisis and may be experiencing a range of emotions; intense, unmet needs for information; and unrealistic expectations of inpatient treatment, as well as having to deal with limited clinician time and confidentiality.33
Outpatient settings require the clinician to work with families to maintain community tenure and promote patient recovery. Clinicians may need to work harder at engaging families in the absence of an acute crisis, but the benefits can be considerable. Clinicians need to remember what available programs they can recommend to family members, including intensive programs such as FPE, the NAMI's FFEP, brief education, and family consultation, as well as regular dialogue and updates.
Techniques for working with families of patients with severe mental illness
|• Family psychoeducation|
|• Family-to-family education program|
|• Family consultation|
|• Brief family education|
|• Family support groups|
|• Regular family treatment planning meetings|