USE OF A MULTI-MODAL MULTIPLE FAMILY GROUP IN THE
COMPREHENSIVE TREATMENT AND REHABILITATION OF
SCHIZOPHRENIA
by
Alexander P. Hyde, M.D.
Charles R. Goldman, M.D.
Alexander P. Hyde, M.D.
Originally presented at American Orthopsychiatric
Association Annual Meeting, San Francisco, CA
March 29, 1988 (Panel 106)
Initially submitted for publication 1/11/88
Revised 7/28/88
ABSTRACT
The authors describe a multiple family group format for treating and rehabilitating schizophrenic patients who live at home. The philosophy, group structure and specific techniques used have been successfully implemented in a private outpatient practice setting, a Community Mental Health Center, and a multidisciplinary mental health professional training program. Out come, requisite leadership skills, and training issues are discussed.
INTRODUCTION
Family oriented treatment (3,6,11,13,14,17,27), "psychoeducation" (2,7,12), and rehabilitation (1,19,21) are increasingly reported as effective in improving the functioning of schizophrenic patients. We, too, have been impressed by the apparent benefits of these and other modalities in improving the lives and clinical status of persons suffering from schizophrenia.
Over the past fifteen years, the senior author of this paper (A.H.) developed an effective format for family oriented treatment/rehabilitation which has now been successfully implemented in a private outpatient practice setting, a Community Mental Health Center, and a multidisciplinary mental health professional training program. The format is unique in its flexible and integrated use of multiple treatment and rehabilitation modalities in a single setting. The purpose of this paper is to describe the model in order to enable its replication, with or without modification, in other treatment and/or training settings.
BASIC PRINCIPLES
Use of the medical model -- We view schizophrenia as a brain disease which interacts with psychosocial factors and which requires medical/psychiatric treatment consisting of accurate diagnosis and skilled psychopharmacological care. We initially emphasize the medical model because it is less threatening and simpler to understand than some of the complex multi-dimensional models, yet allows for later introduction of more advanced topics, such as biopsychosocial interactions and the stress-diathesis theory. "Labeling" the patients as ill, rather than simply having problems in living, leads to discussion of stigma, the "sick role," and prognosis. Fortunately, research suggests that labeling per se does not set up a "self fulfilling prophecy" of lowered expectations and hopelessness (8,22). In fact, in our experience, patients and family members are usually relieved, and eventually encouraged, to hear that there is a "real" brain disease which causes the confusing symptoms with which they are so familiar. Schizophrenia, like other serious illnesses, is viewed as a family stressor which can cause family isolation, distorted communication, and conflict. As the disease improves, the family's condition usually improves, without the need to "diagnose" family pathology and without providing "family therapy" in the usual sense.
Biopsychosocial approach -- We believe that a "holistic" or multimodal approach, which focuses on a variety of biological, psychological and interpersonal factors, is necessary for effective treatment and rehabilitation. We are assertively eclectic in using a combination of pharmacological, behavioral, insight oriented, exhortative, supportive, educational, and social network techniques. Because at least one of the leaders in each group is a psychiatrist, it is possible to use the input of all group members to assist in "fine tuning" medications, a particularly valuable benefit of the multiple family group format.
Patient and family education -- Most affected patients and their families want and need explanation about mental illness, its treatment and rehabilitation in the same way people affected by diabetes, alcoholism, stroke or paraplegia require this information. Multiple family groups are an ideal milieu in which to provide such comprehensive education. It is essential that the feelings generated by discussion of the illness and its consequences be worked through; this includes various stages of grief and mourning. In addition to basic education about the illness, medications and side effects, we include updates on schizophrenia and its treatment as reported in the current scientific literature.
Focus on strengths -- We focus on specific strengths of patients and families (as opposed to looking for pathology), as is dune in rehabilitation of any disorder. To emphasize this point, we view most patients, and their families, as admirably courageous and "tough", otherwise they would not be able to survive as well as they do in the face of such a potentially devastating illness. Many family members, believing that schizophrenia renders its victim totally vulnerable to all stress, become trapped in a "walking on eggshells" mode of behavior. It is therefore helpful to specify the particular kinds of stress that truly exacerbate the illness while encouraging the family to expect "normal" responses from the patient to other kinds of life stress.
Rehabilitation -- In addition to treatment for the disease process itself, we believe rehabilitation of the patient is necessary. Rehabilitation includes (a) learning or relearning life skills, (b) modifying the environment where required to accommodate deficits, (c) initiating or restoring positive physical and mental health habits and (d) facilitating personality changes such as increased assertiveness and more effective coping patterns.
Gradual but steady, stepwise progress -- We believe that many schizophrenic patients respond well to a high, but realistic, set of expectations which are consistent with their personal goals and view of the world. Our approach, therefore, involves forging vigorously but sensibly ahead with small, manageable rehabilitative steps so that failure is unlikely. We try to maintain a steady "therapeutic momentum." While we allow the patients and families to envisage long term goals for themselves, we actively focus only on realistic short term goals. For example, parents are expected to make out a daily list for the patient detailing specific (negotiated) household tasks to perform. When the patient is consistently completing these chores, we expect him/her to add volunteer activities outside the home for several hours per week, proceeding to full-time volunteer work, followed by part-time, then full-time , paid employment. If the family and patient express a desire for the patient to live independently, we help them accomplish the specific steps needed to successfully reach this goal with minimal disruption of family ties. We attempt to set the pace of these incremental steps to the tolerance of the patient and family, with the "rule of thumb" being only one major change at a time. This usually results in a "stair-step" course of improvement, with bursts of change followed by plateaus of consolidation (28). In our experience, it takes an average of two years to accomplish most major rehabilitation goals, but significant early progress in also the rule. As will be discussed in the section on outcome, active rehabilitation must be followed by an indefinite period of maintenance support and "booster" sessions to prevent relapse.
Differentiation of personality factors from schizophrenic behaviors -- Based on a growing body of research, we believe that personality and environmental factors, including family style, are more predictive of favorable or unfavorable outcome than the severity of the schizophrenia itself (4, 5, 9, 10, 19, 26). We therefore teach the families to make a constant effort to differentiate between behaviors due to schizophrenia versus those which stem from the interaction of the patient's personality with his/her environment, including the family. If the behavior is due to the illness (e.g., responding to a hallucination) the treatment is medical, i.e., adjusting medications and/or eliminating specific intoxicants or stressors. If not, the treatment is behavioral and/or insight oriented, in an attempt to improve coping style and interpersonal relationships. Our approach assumes that patients can and must take responsibility for their behavior unless it is clearly and directly due to exacerbation of the basic illness. We challenge every statement that implies that an undesirable behavior is the product of the illness and therefore "can't be helped." Because schizophrenia interferes with developmental processes, we frequently deal with behaviors and interactions commonly seen during adolescence. We also help patients and family members work through the "normal" responses to the stress of severe, chronic illness -- denial, guild, rage, depression -- which can mimic psychopathology.
"Good health habits" -- We believe that the importance of good health habits for any chronic disorder, including schizophrenia, cannot be overemphasized. We use a list of good health principles (15) as a teaching aid and repeatedly focus on patients' adherence to these principles, especially in the initial phase of treatment. The list includes such items as aerobic exercise, following medication regimen, adequate rest, good nutrition, avoiding toxic drugs and "toxic atmosphere," and keeping "steadily, comfortable, usefully active seven days a week." Adherence to these principles seems to ameliorate both positive and negative symptoms, energize the patient, enhance his self-esteem and result in improved family morale.
GROUP FORMATION, STRUCTURE AND RULES
Selection of Patients and Families -- The multiple family rehabilitation group is for adult patients who live in parental homes, or schizophrenic patients living with a non-schizophrenic spouse. Because of the commitment expected, our multiple family rehabilitation group (MFRG) families tend to be relatively stable and already involved with the patient. Based on a recent survey, we estimate that 30 to 40 percent of our local mental health center's schizophrenic population live with such families. We like to work with the whole family, including siblings. We have successfully treated single parent families and married couples, one of whom is schizophrenic (but not both). We insist that fathers attend the group and do not accept families where both parents, when there are two, cannot attend fairly regularly. We usually exclude families with active drug or alcohol abuse occurring in any member. In such cases, prior to joining the group, individual family therapy can be done until the drug or alcohol problem is under control. A small number of families are relatively "slow' in learning and/or implementing the rehabilitation principles; these families need to be involved in a slower paced group or have individual care.
Basic Group Structure and Procedures -- For mutual evaluative purposes, patients and families spend one or two sessions with the groups before signing a one year contract (Appendix A). Most families are seen once or twice individually before entering the group to evaluate their suitability and for explanation of the program. The group meets for 1 1/2 hours weekly, with a monthly group for the family members only (without the patients present) so that the family can bring up issues they might otherwise obit. We tell the families to anticipate two to three years in the group for the most active phase of rehabilitation. To avoid conflicting treatment "messages," once the contract is signed, the group leader(s) become the primary, and preferably the only, "therapist" for the patient. All psychiatric medication management is done by the psychiatrist leader of the group (and/or a psychiatric resident group leader). "Case management" functions are simplified because of the frequency of contact and the presence of the family, which naturally performs many case management tasks (16). On rare occasions, one of the group leaders or students will make a home visit and/or provide some concrete assistance to the patient/family in order to accomplish a particularly critical goal (e.g., go with the patient one or two times until he/she is comfortable with his/her "Meals on Wheels" route).
The group is compose of 4 to 6 families and is "open" in that new families are added as senior ones "graduate." This mix of patients and families at various stages of improvement is helpful because senior families serve as models for the new ones. Individual sessions are provided from time to time as needed through brief conversations before and after the group, through phone contacts and through specifically scheduled sessions with one or more co-leaders. Circumstances rarely require ejection or suspension from the group for such things as regular violations of the contract, unwillingness to follow the contract, or unacceptable behavior in the group or at home. Social activities are arranged by the families for one another and usually occur on weekends; patient-only activities are also arranged, preferably by the patients themselves.
In addition to the leader/teacher, there usually are two to three co-leaders from various disciplines, such as psychiatry, social work, nursing, medical school and chaplaincy, who are learning the techniques; thus, there are between 14 and 18 people present at each group meeting. Also, students may attend one or tow sessions or may observe the groups from behind a one-way mirror. Each MFRG member understands from the beginning that he/she is part of a teaching process and may be observed, with advance notice. In fact, all group members -- leaders, students, families, and patients -- function both as students and as teachers in the sense that they are expected to give supportive care and understanding to one another by sharing their feelings and experience. It is a joy to behold patients and family members who have damaged self images realize that they are being of genuine help to others.
We encourage family members to join the Alliance for the Mentally Ill, and patients to join consumer self-help groups, for personal support, social network expansion, and to help advocate for improved services and elimination of stigma. We have also found that the Alliance helps fill the void that can appear when the patient no longer needs the parents' constant attention. When a patient has achieved his/her goals, patient and family graduate into one of a variety of maintenance groups (patient-only groups, family-only groups, occasional mixed patient-family groups.)
Group Process and Therapist Techniques -- In the early stages, or when a new family enters an ongoing group, group time is spent by the leaders and other knowledgeable members actively teaching about the illness and its treatment/rehabilitation. In addition to didactic teaching, during a "typical" group session, each member reports on the preceding week's events, including progress on assigned "homework," such as building up aerobic capacity, making phone calls for social contact, hunting for a volunteer job. Our "Good Health Habits" list is reviewed with each family and progress is noted and applauded. Group leaders or other members may need to remind or probe individuals for more complete information. A consistent effort is made to foster a group norm of full disclosure of efforts made and results obtained -- evasive answers and "excuse making" are confronted and honesty, even when revealing failure of effort, is praised. Members are encouraged to be spontaneous in their comments, especially in being supportive and giving relevant testimonials. The content of the sessions is balanced with regard to emphasis on serious, "heavy" issues, and lighter, more humorous conversation. Observers are usually impressed with the amount of laughter and fun that punctuates work with such a serious illness.
Frequently throughout the life of the group, the sessions may appear to be individual family counseling in a group context, except that when one family is under discussion, the others are expected to pay close attention (vicarious learning ) and offer feedback and suggestions. An attempt is made to balance the time spent so that all families receive equal group attention. As individual patients improve, group morale and cohesiveness increase, and a constructive positive feedback cycle develops where progress begets progress.
Even though we operate on the assumption that most apparent family "pathology" will disappear after appropriate family education and treatment of the patient, it is important to "diagnose" maladaptive and/or "enabling" patterns that can be more difficult to change. Family behavior which prevents or slows down the treatment/rehabilitation process is confronted, clarified, and worked through using the entire group's input. We interpret these "resistances" as "normal" anxiety about change, or simply as "archaic family systems," rather than as a "need" for the family to maintain a "sick" member.
Group leaders teach by example -- that is, by demonstrating "tough love" techniques and other effective parenting practices, modeling cooperative communication and problem solving, exhibiting positive attitudes, and avoiding over-protective behaviors. Independence and autonomy of the patient is fostered by: encouraging patients to do for themselves whenever possible; emphasizing the patient's right to make independent decisions in strictly personal matters (e.g., dress, music, reading material); encouraging maximum, responsible separation/individuation at every level of improvement and activity (social, vocational, dating, driving, parents going on vacation without the patient); viewing a final leaving home as a natural process which should be handled similarly to non-schizophrenic offspring who leave home; dealing with fears of separation with the usual support and reassurance from the other group families and/or citing past professional experience with other patients.
LEADERSHIP SKILLS REQUIRED
Leaders must be assertive, caring, and genuine. They must demonstrate a compassionate but "tough love" attitude without appearing critical, hostile or patronizing. They must also demonstrate communication skills, particularly honesty and openness thorough revelation on their own human frailties. We encourage leaders to be "human" while retaining leadership and avoiding manipulative "hooks." Leaders are expected to have expertise by virtue of formal clinical training, experience, and ongoing familiarity with the psychiatric literature. Ideally, they will have accumulated enough life experience (wisdom) and clinical sophistication to appreciate multiple levels of meaning in a transaction and choose the relevant level for intervention. We expect them to be sensitive to and learn from patients and families who are also well versed in schizophrenia and are often able to discern vital group and family happenings. As patient, family and group functioning improves, leaders must have the sensitivity and flexibility to lower their profile and allow the group itself, and individuals in the group, to become more "self-directed."
TRAINING ISSUES
The biggest advantage of the multiple family group technique, according to our trainees, is their ability to generalize what they have learned from this experience to their treatment of other schizophrenic patients in various therapeutic situations. Trainees frequently express surprise at how much improvement the patients and families show, thus revising previous pessimistic and otherwise negative attitudes toward the "chronic mentally ill."
One problem has been trainees' difficulty in changing from the traditional "therapist" role into a rehabilitative/teaching one. "Traditional" therapy involves a more passive, reflective process focusing on identifying "bad" or pathological issues as opposed to the assertive, teaching, supportive, "tough love" role that a rehabilitative multi-family group requires. Both roles come into play in these groups, but where conflict occurs, the rehabilitative role takes priority. We also have seen new leaders be reluctant, or find it difficult, to confront patients and families in a kind but firm manner. They sometimes also find it difficult to be open, honest and revealing about themselves as one warm human being to another, without an evasive "defense" of their "professionalism."
Another difficulty we have seen is the trainees' anxieties in handling the many simultaneous, compelling issues that occur in such a large group -- treatment, rehabilitative, intrafamilial and intragroup relationship issues. They may be overwhelmed in the face of the complexity, and consequently have difficulties in adopting priorities of focus. Many mental health professionals also have difficulty developing the required active, empathic, joyous praise and positive reinforcement over their "therapeutic triumphs," such as abstinence from alcohol or caffeine, and first pay check, or the first twenty poind weight loss. Fortunately, with occasional exceptions, the mood of these groups is predominantly active and enthusiastic so that the professionals become accustomed to this style and adopt it willingly.
In our opinion, not every mental health professional should practice this type of rehabilitation. Many find it difficult to discern small but significant changes in "chronic" patients and to derive satisfaction from them, which is the "name of the game" in rehabilitation (18, 23, 24).OUTCOME DATA
Hospitalization Data -- We were able to retrospectively obtain hospitalization data for the ten patients most recently treated in the private practice setting (patients of Alexander P. Hyde, M.D.; groups no longer in existence). All of these patients were in a multi-family rehabilitation group for from one to four years. Collectively, they had thirteen hospitalizations in the two years prior to joining the group. There was one hospitalization during the period of active group involvement. Although there were nine hospitalizations in the two years following termination from the group, there was only one hospitalization in the years following this two year post-group period (range = two to five years as of May, 1988).
Hospitalization data for nine patients who have been in the two multi-family rehabilitation groups which are currently active for at least one year reveals a similar pattern. Collectively, they had ten hospitalizations (plus seven "partial hospitalizations" -- intensive day treatment used as a hospital alternative) in the two years preceding group membership. There were no hospitalizations during active group membership (range = one to 2.5 years). One patient was hospitalized within one year of quitting the group (he had refused any follow-up treatment) and one was hospitalized shortly after rejoining the group following a termination. Seven of the nine patients are currently active in a MFR group (as of May, 1988).
Discussion of Outcome Findings -- The quantitative hospital data provide only a crude picture of the groups' impact. Families of patients who had been out of the group for four to seven years, when re-contacted for follow-up purposes, frequently indicated that the group experience had lasting benefits. Many of the patients relapsed following the abrupt and regrettable discontinuation of the group (when APH left the area), but these relapses appeared to be followed by restoration of a form of group and/or family support which protected both patient and family from further relapses. This subjective impression is consistent with the objective decrease in hospitalization following the initial post-group period. Despite any lasting benefits, however, we believe that patients do better when "graduation" from the MFR group is followed by continued treatment and support, either on an individual basis or in a less intensive patient-only group (with occasional family meetings).
Anecdotal "success stories" are much more striking than the above semi-quantitative data. In dealing with severe, long term mental illness, periodic need for hospitalization does not indicate lack of overall progress. Almost all of the nineteen patients mentioned above have made significant, sometimes dramatic, improvements in their level of function and satisfaction with life. Even more striking has been the apparent improvement in family functioning. Thus, in preventive medicine terminology, multi-family rehabilitation groups, in addition to providing "tertiary prevention" for the involved patients, appear to further the goals of primary and secondary prevention for family members of the severely mentally ill.
CONCLUSION
McFarlane (20) and Piercy, Sprenkle, et al (25) recently reviewed the literature on MFGs and described the following benefits to families:
1) Reversal of stigma and burden (20).
2) Facilitation of disenmeshment of family members (20).
3) Normalization of communication (20).
4) Resocialization and reversal of individual and family isolation (20).
5) Opportunities for families to learn from other families through analogy, indirect interpretation, and modeling (25).
6) Providing a supportive context for trying new behaviors and developing more flexible roles (25).
It is our experience that these benefits indeed occur and, when combined with additional active treatment and rehabilitation interventions, interact synergistically to produce marked improvement in the quality of life of schizophrenic patients and their families. We believe, and preliminary outcome data confirms, that the multi-modal, multiple family group model described in this paper offers a cost-effective treatment/rehabilitation option for selected schizophrenic patients. This model has the added advantage of providing an ideal mechanism for professional level students to learn the principles of psychiatric rehabilitation.
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