The Family Member Provider Outreach Program

ArticleinPsychiatric services (Washington, D.C.) 59(8):934 · September 2008with18 Reads
Impact Factor: 2.41 · DOI: 10.1176/appi.ps.59.8.934 · Source: PubMed

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PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' August 2008 Vol. 59 No. 8
993333
FRONTLINE REPORTS
The Frontline Reports column
features short descriptions of nov-
el approaches to mental health
problems or creative applications
of established concepts in differ-
ent settings. Material submitted
for the column should be 350 to
750 words long, with a maximum
of three authors (one is pre-
ferred), and no references, tables,
or figures. Send material to
Francine Cournos, M.D., at the
New York State Psychiatric Insti-
tute (fc15@columbia.edu) or to
Stephen M. Goldfinger, M.D., at
SUNY Downstate Medical Center
(steve007ny@aol.com).
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HIV prevalence among people with
severe mental illness is roughly ten
times the national average. Inpatient
and outpatient workshops in clinical
settings have improved knowledge,
attitudes, and risk-reduction behav-
iors in this population.
This project took a successful man-
ual-based HIV prevention interven-
tion from the inpatient setting and
adapted it to the clubhouse setting in
the south Bronx in 2006 and 2007.
Clubhouses are traditionally refuges
from the medical model of health
care, and education is a central pillar
of clubhouse activities. The club-
house can be an indispensable site for
preventive health education in the
community. This is the first report of
a community-based HIV prevention
program in the Bronx and the first
such report from any clubhouse in
the United States.
Accurate knowledge about HIV
transmission is already at high levels.
This workshop focused on building
skills through hands-on, group, and
role-play activities to reduce anxiety
and improve decision making in real-
life situations. Activities included
practicing condom use and role play-
ing various scenarios, such as dis-
cussing past risky behaviors with a
new sexual partner, assertively negoti-
ating condom use with a sexual part-
ner, deflecting peer pressure to use
alcohol and drugs, pursuing safe sex
practices while intoxicated, and man-
aging coercive situations.
Workshop sessions were advertised,
coordinated, and facilitated by a fami-
ly and social medicine resident with
medical school experience working in
the clubhouse setting. The clubhouse
director collaborated on advertising at
affiliated residential sites in the month
leading up to each new round of the
workshop. The director also attended
some of the first workshop sessions to
help integrate the workshop facilitator
into the clubhouse community.
The south Bronx clubhouse is
linked to five geographically disparate
residential sites with a total clientele
of roughly 360. During three offer-
ings of the workshop over 18 months,
47 consumers participated, repre-
senting roughly 13% of the target
population. The workshop was con-
sistent with participation rates at oth-
er unrelated clubhouse activities.
The workshop initially consisted of
ten weekly sessions with incentives
that included public transportation
passes, beverages, and condoms at
each session. Classes were scheduled
as a lead-in to weekly free clubhouse
dinners. In order to improve atten-
dance and decrease turnover, the
workshop was reduced to six ses-
sions, and a modest attendance prize
was given at the final session.
Through these interventions, average
attendance increased from five to
seven persons per session, and the
average number of week-to-week re-
turning participants jumped from
three to six. After steady attendance
improvements over three iterations,
a fourth round offered within two
months of the previous session failed
to recruit participants, suggesting
that the workshop would sustain
semiannual repetition but not quar-
terly repetition.
With institutional review board ap-
proval from Montefiore Medical Cen-
ter, we conducted anonymous surveys
during the first and last sessions of
each round of the workshop. Ques-
tions for the survey were borrowed
from previously validated survey in-
struments in the domains of demo-
graphic characteristics, risk factor in-
ventory, knowledge, self-efficacy, and
customer satisfaction. Entrance and
exit surveys were matched by mother’s
birth date, allowing preservation of
anonymity. Transit passes with a value
of $10 were given as an incentive to
participants completing both the en-
trance and exit surveys. More than 40
surveys were completed, but only sev-
en participants completed both the
entrance and exit surveys. Respon-
dents were mostly single, African
American, and ages 25 to 49, with
roughly an equal number of men and
women. Despite promising trends in
knowledge (from 68% to 80%) and
self-efficacy (from 77% to 84%), the
sample was too small to analyze.
Future directions for the project
include expansion of the curriculum
to include other preventive health
topics such as nutrition. Success of
the workshop at the clubhouse led
to an invitation to train staff in HIV
prevention at affiliated residential
sites. The initial group that attend-
ed the workshops may not be the
group most at risk, and expansion
into the residential sites would
therefore be vital. Links were estab-
lished with Montefiore’s medical
school affiliate, Albert Einstein Col-
lege of Medicine, in order to pro-
vide an ongoing, reliable source of
workshop facilitators.
HIV is a serious yet neglected
problem among people with severe
mental illness. Clubhouses are an un-
derutilized facility for preventive
health education in the community.
This intervention deserves further
evaluation as a model for dissemina-
tion to clubhouses across the country.
William B. Jordan, M.D.
Peter A. Selwyn, M.D., M.P.H.
For more information, contact Dr. Jordan
at the Department of Community and
Preventive Medicine, Mount Sinai School
of Medicine, 1 Gustave L. Levy Pl., Box
1043, New York, NY 10029 (e-mail:
william.jordan@mssm.edu). Dr. Selwyn is
with the Department of Family and Social
Medicine, Montefiore Medical Center, Al-
bert Einstein College of Medicine, Bronx,
New York.
Francine Cournos, M.D., and Stephen M. Goldfinger, M.D., Editors
Page 1
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Many benefits of family participation
in evidence-based interventions for
persons with serious psychiatric ill-
nesses have been reported. The
American Psychiatric Association’s
(APAs) 2004 best-practice guidelines
for treatment of schizophrenia and
the Schizophrenia Patient Outcomes
Research Team (PORT) 2003 treat-
ment recommendations urge the use
of family services; in addition, APAs
best-practice guidelines for bipolar
disorder recommend family educa-
tion. Unfortunately, many efforts to
implement family-based services
have resulted in disappointing num-
bers of involved families.
Evidence-based family interven-
tions typically include an initial en-
gagement phase, in which the clini-
cian, not the consumer, assumes pri-
mary responsibility for inviting rela-
tives 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 con-
sistent 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 in-
volved in their treatment and for invit-
ing them to participate should this be
desired. The family member provider
(FMP), who facilitates the interven-
tion, is a relative of a person with seri-
ous 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. Ses-
sions 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 ses-
sions with the FMP. The FMP gets to
know the consumer and uses motiva-
tional interviewing techniques (open-
ended questions, values clarification
tasks, and decisional balances) and
behavioral strategies to help the con-
sumer make deliberative decisions
about involving the family in his or
her care. The consumer also prac-
tices extending an invitation to rela-
tives to join phase 2 of the interven-
tion, should this be the consumer’s
decision. Potential obstacles to in-
volvement are discussed for resolu-
tion. 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 indi-
vidual sessions with the FMP to help
the family connect with the con-
sumer’s treatment team. The FMP
uses motivational interviewing tech-
niques to direct the conversation and
provides basic information on psychi-
atric illness (including facts about the
illness, medication, and relapse pre-
vention). Families receive informa-
tion about contacting the treatment
team and solving potential problems
(such as staff unavailability and con-
cerns 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 treat-
ment team for at least six months. In-
formed consent was obtained from
participants, and all procedures were
approved by the relevant institution-
al 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 per-
cent 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 month-
ly support groups at the VA facility
during the six months after the inter-
vention. After participation in
FMPO phase 1, 13 of 17 (76%) con-
sumers invited their families into
phase 2 of the program. After com-
pleting the FMPO program, 11 of 17
families (65%) had contact with the
treatment team and five of 17 (29%)
attended at least one monthly sup-
port 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 generaliz-
ability of our results to other pro-
viders; and we had data from only
the active treatment group. Never-
theless, 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 psy-
chiatric illnesses. We are now evalu-
ating the intervention in a random-
ized controlled trial.
Shirley M. Glynn, Ph.D.
Lisa B. Dixon, M.D., M.P.H.
Amy Cohen, Ph.D.
Aaron Murray-Swank, Ph.D.
For more information contact Dr. Glynn,
Department of Veterans Affairs (VA)
Greater Los Angeles Healthcare System,
11301 Wilshire Blvd., B151j, Los Ange-
les, 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 Re-
search, Education and Clinical Center
(MIRECC), VA Capitol Health Care Net-
work, 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 Psy-
chiatry and Biobehavioral Sciences,
Semel Institute, University of California,
Los Angeles.
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' August 2008 Vol. 59 No. 8
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FRONTLINE REPORTS
Page 2
    • "These interventions should encourage veterans to identify if and how PTSD affects their intimate relationships to promote insight, as the present study links endorsing such concerns to enhanced interest in partner-involvement. Similar strategies have demonstrated promise in stimulating family engagement in veterans' treatment for serious mental illness (Glynn, Dixon, Cohen, & Murray-Swank, 2008). Related alternatives include Community Reinforcement and Family Training (CRAFT; Miller, Meyers, & Tonigan, 1999), which promotes engagement in care among individuals with substance use disorders through interventions solely with concerned family members, and the Marriage Checkup (Cordova et al., 2005 ), where couples receive feedback on their relationship functioning and motivational interviewing to address relationship distress . "
    [Show abstract] [Hide abstract] ABSTRACT: Associations between PTSD and difficulties in intimate relationships have prompted national calls for partner-involvement in treatment for PTSD. However, research is limited evaluating patient preferences for the format of these services or predictors of these preferences. Such information is vital to shaping services so they are relevant to those most interested in them and to those with greatest need. To address these gaps, we surveyed 185 coupled veterans as they presented for mental health appointments at a VA PTSD treatment clinic. We assessed broad interest in greater partner-involvement, specific interest in couple therapy, and potential predictors of these interests, including family concerns, relationship satisfaction, PTSD symptom severity, and combat era. We found unique positive associations between interest in partner-involvement and both family concerns and relationship satisfaction, suggesting those most interested in partner-involvement are likely those experiencing the greatest family concerns and the most satisfied in their intimate relationships. Associations between interest and PTSD severity were nonsignificant. Interest in couple therapy was significantly greater among returning veterans than Vietnam/Korean War Veterans. However, these two groups did not vary significantly in their interest in greater partner-involvement more broadly. Discussion of findings considers the roles of both insight into PTSD-related family problems and relationship satisfaction in motivating interest in partner-involvement in care, the potential need to address motivation for partner-involvement among veterans in distressed relationships, and the importance of alternative methods of partner-involvement to full courses of couple therapy, particularly for Vietnam/Korean War era veterans. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
    Full-text · Article · Jul 2013 · Psychological Trauma Theory Research Practice and Policy
    0Comments 11Citations
    • "or beliefs about FPE (e.g., ''Family therapy has not worked for my family before—we just fight when we are together.''). Topics and questions to be addressed are listed inTable 3. Engagement in services can be shared with the consumer to explore involvement of his or her relative in treatment, which is highly consistent with the recovery model (e.g., Glynn, Dixon, Cohen, & Murray-Swank, 2008). These engagement techniques can be used with consumers and relatives individually as well as together during a family session and may be particularly effective when commitment falters. "
    [Show abstract] [Hide abstract] ABSTRACT: Family involvement in the care of persons with psychiatric illness is important for recovery-oriented comprehensive mental health services; however, family involvement infrequently occurs. The Department of Veterans Affairs Office of Mental Health Services has sponsored Family Forum II to provide a broad intervention framework for family involvement in the care of persons with psychiatric illness. This article presents guidance provided by Family Forum II. Services highlighted include family consultation, family education, and family psychoeducation; and an intervention framework is presented. Several dimensions of fostering family involvement are emphasized as vital to the process of engagement in meaningful services. An intervention framework for family involvement enables consumers, family members, providers, and administrators to navigate and cultivate family service choices in a family-friendly agency.
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  • [Show abstract] [Hide abstract] ABSTRACT: Mental health authorities across the country face numerous challenges in developing effective and practical strategies to adopt and sustain research-supported and stakeholder-endorsed mental health practices. This column describes how an academic center assists a mental health authority in making policy decisions by the use of advisory panels of multiple stakeholders, including members of the research community, advocacy organizations, service providers, and consumers. An advisory panel that focused on services involving family members for adults with serious mental health problems serves as a case example.
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