Family interventions in adult mental health – the interface with COPMI

• Author: Angela Obradovic is the Chief Social Worker/Family Work Development Coordinator at the Northern Area Mental Health Service in Victoria.
  Brendan O’Hanlon is the Manager of the Mental Health Program at The Bouverie Centre in Melbourne.
  
• Series editors: Andrea Reupert and Darryl Maybery (Monash University) on behalf of the COPMI national initiative.

Quick facts

• Family Psycho-Educational (FPE) interventions that typically target the family of origin of an adult diagnosed with a mental illness, reduce symptoms and relapse, improve medication adherence and the social functioning of the person experiencing the condition. These interventions also reduce distress and burden in primary carers and improve family functioning.
• Common features of FPE interventions include involvement of the person with the condition, a practitioner attitude towards families that is non-blaming and collaborative, an acknowledgement of each individual family member’s needs, sharing information about the condition and the impact of illness on relationships, the development of relapse prevention plans and the teaching of communication and problem solving skills.
• There is great potential for cross-fertilization of FPE and COPMI family interventions in relation to research and practice development.

Research summary

There are numerous effective family intervention programs for families where an adult member has a mental illness that have been the subject of meta analyses and systematic reviews.

This GEMS summarises the evidence relating to one group of family interventions. These are most commonly implemented within adult mental health services and are primarily targeted at adults with a diagnosed mental illness, usually schizophrenia or bipolar affective disorder. While not excluding families with dependent children, these interventions typically involve the adult with the condition, their parents and adult siblings – often referred to as the ‘family of origin.’ Research evaluating these programs shows significant improvements for both the individuals with the conditions as well as their families and carers.¹

In contrast, ‘COPMI’ family interventions (featured in GEMS edition 13) involve an adult with a mental illness who is the parent of dependent children, their partner and children – a group usually referred to as the ‘family of procreation or choice.’ These interventions have often focussed on high prevalence conditions such as depression and specifically aim to address parenting issues and needs. The evidence in relation to these interventions points to a reduction in the risk of the development of mental illness in children.²

While these two parallel traditions of practice and research share an interest in intervening with families affected by mental illness, they have developed in relative isolation from each other and focus on different outcomes, family constellations and psychiatric diagnoses.

Adult Focussed Family Psychoeducation Models

A group of family interventions termed Family Psycho-Education (FPE) have been widely used and extensively researched in adult mental health services. Although FPE can be conducted in a single family format (for example Behavioural Family Therapy -BFT) or multi-family format (for example Multiple Family Groups -MFG), these interventions share a number of important features.

These include the following:

• A practitioner attitude towards families that is non-blaming and collaborative
• An acknowledgement of each individual family member’s needs
• Sharing information about the condition and the impact of illness on relationships
• The development of relapse prevention plans
• The teaching of communication and problem solving skills.

Multi-family formats additionally utilise peer support as a key element of the approach.

A feature that distinguishes these approaches from education programs for carers or families is that the person with the illness is included in the work with the family. Including the person with the condition and a time frame of six to nine months are seen as critical to the effectiveness.^3-5

Family Consultation is a brief family intervention model used in adult mental health services that responds to family’s expressed needs and often provides a ‘gateway’ to the more intensive FPE interventions.⁶

More than 50 randomised control trials of FPE in the treatment of schizophrenia have been conducted over the last 35 years with the most consistent findings showing significant reductions in relapse and hospital admission rates. Other findings for the person with the condition include improved adherence with medication, reduced symptoms and improved social functioning and vocational activity.¹ In addition, these interventions have been shown to reduce distress and burden in primary carers and improve family functioning.⁷

Adaption of FPE for COPMI

BFT and Family Consultation have been adapted to address the needs of COPMI in Australia and the United Kingdom.⁸ One example, the Building Family Skills Together Mind Program, a small Melbourne-based BFT team, modified the BFT assessment processes, schedules and information provision to suit young children. This team found that children as young as five can usefully participate in BFT.⁹

Limitations of Research

Despite the benefits of FPE for adults experiencing serious mental illness and their families, there is no published research about the specific application of these approaches to families where a parent has a mental illness. The parental status of the person experiencing schizophrenia or the presence of dependent children is typically not reported in research on FPE. As such, there is no data examining the impact of FPE on variables such as parental functioning or the well-being of dependent children.

Practice Implications

Effective models of family intervention already exist within the adult mental health context. Parents who can currently access these interventions can discuss with practitioners whether parenting issues can be included in the intervention and whether the direct participation of their children is appropriate. Given that interventions developed specifically for COPMI and FPE share a psychoeducational orientation, there is potential to adapt FPE to incorporate useful features of COPMI family interventions. This would take advantage of the existing acceptability of FPE within adult mental health services by incorporating a more child-parent inclusive approach into the existing evidence based family practice recommended for this context.

1. Pharoah F, Mari J, Rathbone J, Wong W. Family intervention for schizophrenia. Cochrane Database of Systematic Reviews. 2010;12.
2. Siegenthaler E, Munder T, Egger M. Effect of preventive interventions in mentally ill parents on the mental health of the offspring: Systematic review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry 2012;51(1):8-17.
3. Harvey C, O’Hanlon B. Family psycho-education for people with schizophrenia and other psychotic disorders and their families. The Australian and New Zealand Journal of Psychiatry. 2013 Jun;47(6):516-20. PubMed PMID: 23393269. Epub 2013/02/09. eng.
4. Lucksted A, McFarlane WR, Downing D, Dixon LB. Recent developments in family psychoeducation as an evidencebased practice. Journal of Marital and Family Therapy. 2012;38(1):101-21.
5. Bradley G, Couchman G, Perlesz A, Nguyen AT, Singh B, Riess C. Multiple-Family Group treatment for English and Vietnamese-speaking families living with schizophrenia. Psychiatric Services. 2006;57(4):521-30.
6. Jewell TC, Smith AM, Hoh B, Ladd S, Evinger J, Lamberti JS, et al. Consumer centered family consultation: New York State’s recent efforts to include families and consumers as partners in recovery. American Journal of Psychiatric Rehabilitation. 2012 2012/01/01;15(1):44-60.
7. Cuijpers P. The effects of family interventions on relatives’ burden: a meta-analysis. Journal of Mental Health. 1999;8(3):275-85.
8. Whole Family Approaches Birmingham: Birmingham and Solihull Mental Health NHS Foundation Trust; 2015 [23/02/2015]. Available from: http://www.meridenfamilyprogramme.com/family-work/whole-family-approaches.
9. Hamann J, Whatley E. Working with ‘hidden’ families: Evaluating the Building Family Skills Together (BFST) Mind program. New Paradigm: The Australian Journal on Psychosocial Rehabilitation. 2011 (Summer):50-2.