Multifamily Group Psychoeducation 
Evidence-based practice with a multidisciplinary approach 

The following abstract was published in Advance for Nurses, August 29, 2005 - Vol. 7, Issue 19, Page 41.

By Edward Owens, RN,BC, & Sarah Lynch, LCSW 

Ed Owens is a nurse and Sarah Lynch is a social worker at the Center for Psychiatric Research of the Mental Health Network of Maine Medical Center and Spring Harbor Hospital, Portland, ME. Both co-facilitate multifamily groups. 

William, a 30-year-old man with schizophrenia, recently moved back to his parents' home as he is unable to live on his own. He cannot hold on to a job and his compliance with medication is sporadic. His parents, once very active in their church and community, stopped attending events due to William's unpredictable and sometimes embarrassing behavior. The family is very critical of William, which increases his stress, which in turn increases his psychiatric symptoms. He has been hospitalized multiple times, and the family becomes more discouraged each time. 

Upon his last hospitalization, the treatment team recommends William and his family attend a multifamily group with other families who have had similar experiences with mental illness. The team believes this will help prevent William from continuing to cycle in and out of the hospital. 

This case study is typical of many families dealing with a family member newly diagnosed with schizophrenia or bipolar disorder. Parents' hopes and dreams of an independent life for their child are initially shattered. They feel vastly different from their friends who share their children's successes at college or in employment. 

In such cases, psychoeducation is critical. And while there are many
effective formats for providing psychoeducation to families in this
situation, the multifamily group (MFG) is unique because it includes the patient. Research suggests patients improve through participation in MFGs alongside their family members and other caring people. They benefit from the social interaction with other patients and families, improving their social skills and broadening their social networks. 


A Change of Heart 

Prior to the 1990s, families were often seen as the cause of a mental
illness in their child and therefore alienated from the young person's
treatment and recovery. In an outpatient setting, family members were sent to the waiting room; in an inpatient setting, they were informed of admission and discharge but were not given an active role in creating a supportive aftercare plan. 

This nonintegrated approach leaves family members' questions and
concerns unaddressed. The most important resource for the client is not utilized. Therefore, families may harbor resentment or feel resigned to a role of lifelong caregiver. Family members are confused about what has happened and why, and parents often blame themselves or find fault with their loved one. Families don't know how to maintain any normal routine because they may fear for their loved one's safety or feel the need to be home to monitor symptoms and behaviors. Emotional over-involvement of parents at home can lead to resistance on the part of the young person and impact job performance and social functioning of all family members.


In contrast, MFGs encourage families to participate in treatment and are seen as a valuable support in the rehabilitation process. A number of research studies demonstrate that MFGs reduce relapse rates for consumers compared to other methods of intervention. 

Although most of the evidence of MFG efficacy is based on groups
comprised of people with chronic and persistent mental illnesses and
their families, new studies are focusing on MFGs for clients at the
pre-illness or first episode phase of symptom onset. 

The earlier families can work together in a collaborative setting with
other families, the less they will need crisis services and
hospitalization. 

A meta-analysis of data from longitudinal studies conducted between 1980-1997 show the relapse rate is 65 percent for patients taking no medication, and 30-40 percent for patients in individual therapy and taking medication or taking medication alone. However, the relapse rate is only 15 percent for patients in multifamily groups and taking medication.1 

Additionally, multiple studies have shown a broad scope of functional outcomes including improved well-being among family members, increased patient participation in vocational rehabilitation, substantially increased employment rates, decreased psychiatric symptoms, improved social functioning, decreased family medical illness and medical care utilization, and reduced costs of care.1 


Getting Started 

In essence, MFGs offer members the support of other families going
through a similar journey. They aim to reduce symptoms of mental illness caused by stress, reduce risks for relapse, and involve family members and friends in the treatment of the patient. 

MFGs are run by co-facilitators, preferably from differing disciplines:
combinations of nurses, psychiatrists, social workers, psychologists,
employment specialists and occupational therapists. Initially, the group provides families with information about the illness, stress reduction techniques and guidelines for recovery. The longer term outcome is a network of families using each other as a social support.2 

The clinician's role initially is to enter family members into a
structured joining process, which consists of three sessions and an
educational workshop, so each family comes into the group with the same knowledge base. These initial "joining" meetings are conducted in the same format as the group, with a socializing time at beginning and end to establish a comfort level and partnership between clinicians and families. 

The clinicians engage with new families to review their present crisis,
identify early warning signs or events, and share coping skills and
supports that have been helpful to other family members. History is
gathered from each family member about how the illness of their loved one has impacted them. The focus is on both patient and family strengths, interests and goals, as well as social networks. 

It is important for family members to agree on some common goals for group participation. 

Once the group begins, MFGs typically meet twice a month for 90 minutes per session. Groups may include a light supper or pot luck snack food. An MFG's duration varies, but at least 1 year of participation is recommended. Groups can continue to run for as long as members benefit, and may meet less frequently over time, such as monthly as opposed to biweekly. Depending on the clinical setting and numbers of participants, groups may be open or closed. 


Problem-Solving 

The MFG is structured around a problem-solving format that allows
families to practice guidelines for recovery on a day-to-day basis. Each group session focuses on a specific problem, chosen as a result of a group-wide "check-in." 

After an initial socializing, all members are asked, "What is going well and what could be better since last group?" The two group leaders address all concerns and begin to formulate a problem specific enough that an action plan can be achieved in the coming 2 weeks. 

All participants offer solutions to the identified problem. Ultimately,
the identified group member chooses which solutions will work best for him or her. An action plan is developed and then reviewed at the next group. Some examples of problem-solving topics include: 

-managing the stress of transitioning to a new job or school; 

-finding enjoyable activities while coping with negative symptoms of
schizophrenia; 

-remembering to take medication every day; 

-how parents can check in about symptoms without hovering or increasing
stress for their child; and 

-how parents can find time for their own interests. 

Every idea suggested by a group member is considered without judgment.
Once a number of solutions are offered, discussion of pros and cons is a collective effort of the group, giving value to each person's input.
Families notice that the young person is more apt to accept advice from peers and family members in the group other than their own.
Cross-parenting can be extremely effective. Providers often see a
dynamic where group members impart knowledge and skills to other group members. 

The goal of the problem solving is to reduce everyday stressors and
improve communication amongst family members. The group's process models healthy and collaborative solution-building for families. It's hoped that once families practice these skills over time within the group, they will continue to use this approach to reduce stressors and improve communication at home. 


Creating Hope 

William's family now attends MFG regularly. His parents come even when William is unable to be there. Gradually, William's relationships with his parents improved. He is able to hold onto a job and ask for the support he needs. He has not been hospitalized since his parents started the group; he and his parents look forward to attending MFG and interacting with other families. 

If you would like to find out more about training and implementation of MFG psychoeducation, call 877-880-3377. 


References 

1. McFarlane, W.R., et al. (2003). Family psychoeducation and
schizophrenia: A review of the literature. Journal of Marital & Family Therapy, 29, 223-245. 

2. McFarlane, W.R. (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York: The Guilford Press. 

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