Family Psychoeducation (FPE)

Family Psychoeducation (FPE)

What Is Family Psychoeducation?

Family Psychoeducation (FPE) is an approach for partnering with consumers and families to treat serious mental illnesses. FPE practitioners develop a working alliance with consumers and families.

The term psychoeducation can be misleading. While FPE includes many working elements, it is not family therapy. Instead, it is nearly the opposite. In family therapy, the family itself is the object of treatment. But in the FPE approach, the illness is the object of treatment, not the family. The goal is that practitioners, consumers, and families work together to support recovery.

Serious mental illnesses such as schizophrenia, bipolar disorder, and major depression are widely accepted in the medical field as illnesses with well-established symptoms and treatment. As with other disorders such as diabetes or hypertension, it is both honest and useful to give people practical information about their mental illnesses, how common they are, and how they can manage them.

Many consumers and families report that this information is helpful because it lets them know that they are not alone and it empowers them to participate fully in the recovery process. Similarly, research shows that consumer outcomes improve if families receive information and support (Dixon et al., 2001). For this reason, a number of family psychoeducation programs have been developed over the past two decades.Models differ in their format (whether they use a multifamily or single-family format); duration of treatment; consumer participation; and location. Research shows that the critical ingredients of effective FPE include the following (Dixon et al., 2001):

• Education about serious mental illnesses;
• Information resources, especially during periods of crises;
• Skills training and ongoing guidance about managing mental illnesses;
• Problem solving; and
• Social and emotional support.

The phases of Family Psychoeducation

FPE services are provided in three phases:

1. Joining sessions;
2. An educational workshop; and
3. Ongoing FPE sessions.

1. Joining sessions:

Initially, FPE practitioners meet with consumers and their respective family members in introductory meetings called joining sessions. The purpose of these sessions is to learn about their experiences with mental illnesses, their strengths and resources, and their goals for treatment.

FPE practitioners engage consumers and families in a working alliance by showing respect, building trust, and offering concrete help. This working alliance is the foundation of FPE services. Joining sessions are considered the first phase of the FPE program.

2. Educational workshop:

In the second phase of the FPE program, FPE practitioners offer a 1-day educational workshop. The workshop is based on a standardized educational curriculum to meet the distinct educational needs of family members.

FPE practitioners also respond to the individual needs of consumers and families throughout the FPE program by providing information and resources. To keep consumers and families engaged in the FPE program, it is important to tailor education to meet consumer and family needs, especially in times of crisis.

3. Ongoing Family Psychoeducation sessions:

After completing the joining sessions and 1-day workshop, FPE practitioners ask consumers and families to attend ongoing FPE sessions. When possible, practitioners offer ongoing FPE sessions in a multifamily group format. Consumers and families who attend multifamily groups benefit by connecting with others who have similar experiences. The peer support and mutual aid provided in the group builds social support networks for consumers and families who are often socially isolated.

Ongoing FPE sessions focus on current issues that consumers and families face and address them through a structured problem-solving approach. This approach helps consumers and families make gains in working toward consumers’ personal recovery goals.

FPE is not a short-term intervention. Studies show that offering fewer than 10 sessions does not produce the same positive outcomes (Cuijpers, 1999). We currently recommend providing FPE for 9 months or more.

In summary, FPE practitioners provide information about mental illnesses and help consumers and families enhance their problem-solving, communication, and coping skills. When provided in the multifamily group format, ongoing FPE sessions also help consumers and families develop social supports.

Practice principles

FPE is based on a core set of practice principles. These principles form the foundation of the evidence-based practice and guide practitioners in delivering effective FPE services.

Principle 1: Consumers define who family is.

In FPE, the term family includes anyone consumers identify as being supportive in the recovery process. For FPE to work, consumers must identify supportive people they would like to involve in the FPE program. Some consumers may choose a relative. Others may identify a friend, employer, colleague, counselor, or other supportive person.

Principle 2: The practitioner-consumer-family alliance is essential.

Consumers and families have often responded to serious mental illnesses with great resolve and resilience. FPE recognizes consumer and family strengths, experience, and expertise in living with serious mental illnesses.FPE is based on a consumer-family-practitioner alliance. When forming alliances with consumers and families, FPE practitioners emphasize that consumers and families are not to blame for serious mental illnesses. FPE practitioners partner with consumers and families to better understand consumers and support their personal recovery goals.

Principle 3: Education and resources help families support consumers’ personal recovery goals.

Consumers benefit when family members are educated about mental illnesses. Educated families are better able to identify symptoms, recognize warning signs of relapse, support treatment goals, and promote recovery. Provide information resources to consumers and families, especially during times of acute psychiatric episodes or crisis.

Principle 4: Consumers and families who receive ongoing guidance and skills training are better able to manage mental illnesses.

Consumers and families experience stress in many forms in response to mental illnesses. Practical issues such as obtaining services and managing symptoms daily are stressors. Learning techniques to reduce stress and improve communication and coping skills can strengthen family relationships and promote recovery. Learning how to recognize precipitating factors and prodromal symptoms can help prevent relapses. For more information, see Training Frontline Staff in this KIT.

Principle 5: Problem solving helps consumers and families define and address current issues.

Using a structured problem-solving approach helps consumers and families break complicated issues into small, manageable steps that they may more easily address. This approach helps consumers take steps toward achieving their personal recovery goals.

Principle 6: Social and emotional support validates experiences and facilitates problem solving.

FPE allows consumers and families to share their experiences and feelings. Social and emotional support lets consumers and families know that they are not alone. Participants in FPE often find relief when they openly discuss and problem-solve the issues that they face.

How we know that Family Psychoeducation is effective

FPE is based on research that shows that consumers and families who participated in the components of the evidence-based model had 20 to 50 percent fewer relapses and rehospitalizations than those who received standard individual services over 2 years (Penn & Mueser, 1996; Dixon & Lehman, 1995; Lam, Knipers, & Leff, 1993; Falloon et al., 1999). Those at the higher end of this range participated for more than 3 months.

Studies also show that FPE improved family well-being (Dixon et al., 2001). Families reported a greater knowledge of serious mental illnesses; a decrease in feeling confused, stressed, and isolated; and reduced medical illnesses and use of medical care (Dyck, Hendryx, Short, Voss, & McFarlane, 2002).

FPE has been found to increase consumers’ participation in vocational rehabilitation programs (Falloon & Pederson, 1985). Studies have shown employment rate gains of two to four times baseline levels, when combined with evidence-based practice Supported Employment (McFarlane, Dushay, Stastny, Deakins, & Link, 1996; McFarlane et al., 1995; McFarlane et al., 2000).

Based on this significant evidence, treatment guidelines recommend involving families in the treatment process by offering the critical ingredients outlined in this evidence-based model (Lehman & Steinwachs, 1998; American Psychiatric Association, 1997; Weiden, Scheifler, McEvoy, Allen, & Ross., 1999).

Who benefits most from Family Psychoeducation?

The greatest amount of research has shown benefits for consumers with schizophrenic disorders and their families (Dixon et al., 2001). Studies also show promising results for the following illnesses:

• Bipolar disorder—(Clarkin, Carpenter, Hull, Wilner, & Glick, 1998; Miklowitz & Goldstein, 1997; Moltz, 1993; Parikh et al., 1997; Miklowitz et al., 2000; Simoneau, Miklowitz, Richards, Saleem, & George, 1999);
• Major depression—(Simoneau et al., 1999; Emanuels-Zuurveen & Emmelkamp, 1997; Leff et al., 2000);
• Obsessive-compulsive disorder—(Van Noppen, 1999); and
• Borderline personality disorder—(Gunderson, Berkowitz, & Ruizsancho,, 1997).

Studies show that the effectiveness of FPE does not differ depending on consumers’ age, gender, education-level, or severity of illness. This model has also been adapted and used effectively with a number of ethnic groups in a variety of settings in the United States. Studies have also been conducted in England, Spain, Germany, and China.

Although more replications are desirable, all the evidence to date suggests that the positive effects of FPE generalize to nearly all major cultural populations: British, American, Australian, African American, Spanish or Latino, Scandinavian or Northern European, Chinese, and Japanese. However, anecdotally we know that culture and language pose significant barriers to providing FPE in some populations and, in any case, require culturally sensitive adaptations that must be further explored empirically.

Is Family Psychoeducation for the family’s benefit or for the consumer’s?

FPE is for both consumers and families. The goal is to support recovery from serious mental illnesses. The evidence-based model asks family members to help in that effort. Though it is designed to achieve clinical outcomes and recovery goals for consumers, beneficial effects have been found for families as well.

What if consumers do not have family or do not want their families involved?

In FPE, the term family includes anyone consumers identify as being supportive in the recovery process. The broad definition emphasizes that consumers choose whether to involve family and whom to involve. FPE helps consumers develop or enhance their support networks.

The evidence-based model has been found to work well with consumers who are disengaged from their families and have difficult treatment histories. Joining sessions give practitioners the opportunity to help consumers engage family members again in a constructive and supportive manner.

Research shows that practitioners often ask consumers for permission to involve their family members during a crisis (Marshall & Solomon, 2003). Asking for family involvement at this time may raise suspicions for some consumers. Consequently, they may be more reluctant to identify supportive people. For this reason, modify your intake and assessment procedures so that consumers are routinely told about the FPE program and are periodically asked if they would like to involve someone supportive in their treatment.

If consumers do not wish to involve family members in their treatment, FPE practitioners should respect their decision. If consumers do not give permission to share confidential information with their families, FPE practitioners may still respond to families’ questions and concerns. Even the strictest interpretation of confidentiality policies does not prohibit receiving information from families or giving them general information about serious mental illnesses and agency services (Bogart & Solomon, 1999; Zipple, Langle, Spaniol, & Fisher, 1997).

If families want to learn more about serious mental illnesses, FPE practitioners should direct them to local family organizations such as the National Alliance on Mental Illness (NAMI). Consumers who are not interested in FPE may benefit from other education and skills training programs that are targeted specifically to consumers such as Illness Management and Recovery. For more information, see the Illness Management and Recovery KIT.

Where should Family Psychoeducation be provided?

The FPE multifamily group model was first developed in a partial hospital setting. Nearly all of the controlled research on effectiveness has been conducted in outpatient clinics and community mental health centers. The extent to which FPE can be successfully adapted to other types of agencies is unknown.

FPE has been successfully implemented in both urban and rural settings, as well as in mid-sized cities and suburbs. For more information, see The Evidence in this KIT.

Is it cost effective?

Implementing an FPE program has initial costs related to training and program development. However, studies show a low cost-benefit ratio related to savings from reduced hospital admissions, hospital days, and crisis intervention contacts (McFarlane, Dixon, Lukens, & Lucksted, 2003).

Cost-benefit ratios vary by state. For example, in New York, for every $1 in costs for FPE provided in a multifamily group format, a $34 savings in hospital costs occurred during the second year of treatment (McFarlane, 2002). In a hospital setting in Maine, an average net savings occurred of $4,300 per consumer each year over 2 years. Ratios of $1 spent for this service to $10 in saved hospitalization costs were routinely achieved.

Non-fiscal savings are achieved as complaints from families about services decrease and family support for the agency and the mental health authority grows. In many communities, this has translated into political support for funding for expanded and improved services.

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