PEPP provides individual family intervention to families of persons who are experiencing a first episode psychosis. Very often, the first contact with families is made during crisis. Successful engagement of these families is crucial for ongoing contact. The sensitivity shown to families during this time often sets the tone for ongoing treatment. The schedule for individual family intervention is unstructured and depends on family needs. It can be delivered in the environment of choice - home or clinic. Some families want frequent and consistent contact with the team while other families disengage after the crisis. The following is a description of the most common pattern of family contacts.
Most often, family member(s) are seen for the first time during the screening interview which occurs during a time of crisis or prolonged stress of seeking help for their relative. Although the case manager may have had telephone contact with the family through the referral process, the screening interview is often the first face-to-face encounter. The assessment clinician (case manager) must be very sensitive to the circumstances and needs of family members at this time. The family should be given an opportunity to tell their story of the client's problem in a separate interview without the client and after the client has been seen. This opportunity may arise during the completion of the screening inventories. The first contact should be mainly confined to obtaining information rather than giving too much factual information about psychosis.
If the client has been identified through hospital admission, the inpatient social worker will conduct the initial family assessment. Every effort should be made to establish contact with families at the earliest possible time. Home visits to the family during the clientÕs hospitalization are often a very effective means in engaging the family in the treatment process. Strong liaison between the social worker and the case manager is necessary.
If the family is not seen at the time of the outpatient screening, they are urged to attend the two-hour initial assessment. The psychiatrist interviews the client while the family meets with the case manager. The family often provides either the first pieces of information or additional information pertaining to the client's problem including birth history, milestones, school achievement, medical problems, peer relationships, drug and alcohol use, family history, etc. At the conclusion of the initial assessment, the case manager and family meet with the psychiatrist and client to share information and decide on a plan of care. The case manager schedules all future contacts. The psychiatrist may indicate when he/she would like to see the family again, but most likely he/she will rely on the communication from the case manager to set up appointment times.
The next most important step in the family intervention process is an invitation to the psychoeducational workshop which provides the foundation of the information that the family will require to help their relative. In the meantime, the case manager will continue to assess the family's needs and strengths in addition to providing individual support and education. The family intervention is guided by the Wisconsin Quality of Life measure that identifies their goals and concerns for the client and themselves.
All subsequent contacts are carried out in the clinic or in the family home as dictated by needs and preference. Continual reference to the families' stated goals helps guide the frequency of contacts. It is necessary to have a proactive stance rather than a reactive one in meeting the needs of families. Confidentiality may become an issue as the client recovers. The age of the client may also affect confidentiality. Young adult clients are often hesitant to let parents accompany them to appointments or to discuss illness related issues, whereas the adolescent client who is emotionally and financially dependent upon family is less hesitant, except in drug and alcohol related issues. The challenge for the case manager is to create ways of including family without sacrificing the therapeutic relationship and first priority of care to the client. Clients will be included in family contacts to avoid arousing uncertainty and mistrust. Contracting agreements with clients to allow family to communicate concerns about symptoms, treatment response and side effects are often helpful in promoting trust and a working partnership between the client, his/her family and the treatment team.
At the end of one year of treatment, the family is asked to complete the Quality of Life Inventory again. This provides the case manager and family another opportunity to re-assess and review goals and concerns. The family intervention, although highly standardized for the workshop segment, is not as well defined for the individual intervention. This will be addressed in the near future.
NOTE: A new teaching program for families has been developed by us. This consists of three separate video modules each accompanied by a workbook. The modules provide guidelines regarding all major issues faced by families of first episode psychosis patients. These are be available by request from PEPP.
A multiple family group intervention program will begin in 2001 in collaboration with Dr. W. McFarlane, Portland, Maine.