Working with Families

Report
Working with Families
Linda May, PhD, MFT – Case Manager, PART
The experience of working with families
What would you want
if you or a loved one developed
a high risk or psychotic illness?
What would you expect
would be the stressors, skill deficits,
AND
Areas of strength
Systems - homeostasis
Mother
Father
Son
Daughter
Mother
Son at college
Grandfather
Grandmother
Organizational Homeostasis
Adolescent/Young Adult
with High Risk or SMI
Mother
Father
Living with Second Family
Younger Sibling
Second Wife
7 yr old son
3 yr old daughter
Genogram
Julie
Stillbirth male 1992
-----
Dan
Susannah 1994
Margaret 1998
Family therapy – then and now
• Dysfunctionality based approaches
• Best possible outcome for consumer and
family thru collaboration
• Evidence-based family intervention
Functional & Problem Behaviors
Functional
Problem
Family work in prodrome, and early
psychosis
• Research supports need for
comprehensive txt – meds, family wk,
milieu/occupational, & psychosocial
• Earlier treatment improves prognosis
• Support and education of individual and
family
• Family may be main caregiver
Ultra High Risk & Psychosis in
Developmental Perspective
• Normal development
individuation, formal operations, identify
formation, family system
temperaments, significant life events
• Ultra High Risk & Psychotic symptoms –
impact on communication, expectations
Family as support vs. stressor
• Family style (EE research) pre, post
symptoms
• Stigma impact
• Lack of comprehensive support network
• “Warm, positive” versus “critical,
overprotective”
Components of expressed emotion:
Prodromal vs. chronic phase
7
SAS-III score
6
5
4
3
2
1
Chronic
schizophrenia 1
Warmth
Chronic
schizophrenia 2
Rejection
Prodromal
Mothers
Protectiveness
Fusion
SAS-III, Rejection and Emotional Over-involvement subscales
All differences, prodromal vs. chronic: p<0.01
Prodromal
Fathers
Effects of EE and contact on
relapse in schizophrenia
60
58.8
50
41.7
40
High contact
Low contact
30
23.9
18.3
20
10
0
High EE
Bebbington and Kuipers, 1994
Low EE
Family Guidelines
• System changes, sib realignment, need for
family support
• Grief, loss regarding “former child”
• Impact on parental identification
• Impact on “launching” plans
• Impact on child’s individuation, identity
with adolescent, young adult peers
Social networks in schizophrenia
• Family network size
– diminishes with length of illness
– decreases in the period immediately
following a first episode
– is smaller at the time of first admission
• Networks
– buffer stress and adverse events
– determine treatment compliance
– predict relapse rate
– correlate with coping skills and burden.
Key family interventions specific to
prodromal psychosis
• Strengthening relationships and creating an optimal,
protective home environment
–
–
–
–
Preventing onset of negativity and criticism
Reducing intensity, anxiety and over involvement
Adjusting expectations and performance demands
Minimizing internal family stressors as marital stress, sibling
conflict/concerns, conceptual and attributional confusions and
disagreement
References
• Family Guidelines – Sources: Carol Anderson, Schizophrenia and
the Family (Guilford Press, 1986); Dr. William McFarlane, MultiFamily Groups in the Treatment of Severe Psychiatric Disorders
(Guilford Press, September 2004).
• Concepts & Recommendations for clinicians Who Teach Families
How to Manage Schizophrenia by Carole M. Anderson, Douglas J.
Reiss, William R. McFarlane, MD
• Family Expressed Emotion Prior to Onset of Psychosis – William R.
McFarlane, MD, William L. Cook, PhD
• Family Psychoeducation and Schizophrenia: A Review of the
Literature – William R. McFarlane, Lisa Dixon, Ellen Lukens, Alicia
Lucksted
• Multifamily Groups in the Treatment of Severe Psychiatric Disorders
by William R. McFarlane

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