[Episode 27] In today's podcast, I speak with Carol Anderson, who along with Gerry Hogarty, developed a family-based approach to working with people with schizophrenia called Family Psychoeducation. Family Psychoeducation is only one of a handful of treatments that has been empirically validated to improve the lives of people with serious mental illness. According to the American Psychiatric Association, when people with schizophrenia are involved in family psychoeducation while taking medication, there is a significant reduction in relapse and unemployment. In today's podcast, Carol describes the 5 stages of psychoeducation, distinguishes between psychoeducation and other forms of family therapy, provides some anecdotes about family psychoeducation treatment, and provides some information for people interested in learning how to do family psychoeducation.Carol Anderson, Ph.D. is a Professor of Psychiatry and Social Work at the University of Pittsburgh Medical Center. Her current research focuses on access to mental health care, barriers to services, and issues of engaging low income mothers and other clients in treatment. She has long-term interests in marital and family therapy and the impact of mental illness on families. She is a prolific contributor to the field of family therapy, has served as President of the American Family Therapy Academy, and has received national awards for her distinguished contributions to the field. She has authored and coauthored over 40 articles and several books including Women in Families, Mastering Resistance, Families and Schizophrenia, and Flying Solo. She is also a Distinguished Daughter of the State of Pennsylvania.
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Introduction
Jonathan Singer: Schizophrenia continues to be one of the most publicly misunderstood and stigmatized of all mental illnesses. For much of the 20th century, neither psychotherapy nor medication provided much relief for people with this serious and persistent mental illness. Psychotherapists blamed the mother and ultimately the family for causing schizophrenia. Medication reduced psychotic symptoms without increasing the person’s ability to function. Because there were no effective treatments, people with schizophrenia were first institutionalized and then during the deinstitutionalization movement, they were released to communities who were unprepared to treat them. It was during this period that two social workers Gerry Hogarty and Carol Anderson developed what would become the first empirically validated family therapy for people with schizophrenia. In their 1986 manual on family psychoeducation, Carol and her colleagues described the climate in which they developed their treatment. Here’s Carol reading a brief quote.
Carol Anderson: “We have blamed each other, the patients themselves, their parents and grandparents, public authorities and society for the cause and for the terrible course of these mental disorders. When hope and money become exhausted, we frequently tear schizophrenic patients from their families consigning them to the existential terror of human warehouses, single room occupancy hotels and more recently to the streets and alleys of American cities.”
Jonathan Singer: Even though this quote describes the policies and attitudes of America 30 years ago, the prevalence rates for disorders such as schizophrenia have not decreased. There continues to be a significant need for effective treatments. In today’s podcast, I speak with Carol Anderson about family psychoeducation. According to the American Psychiatric Association, when people with schizophrenia are involved in family psychoeducation while taking medication, there's a significant reduction in relapse and unemployment. Family psychoeducation is only one of a handful of treatments that’s been empirically validated to improve the lives of people with serious mental illness. In today’s podcast, Carol describes the five stages of psychoeducation. She distinguishes between psychoeducation and other forms of family therapy, provides some anecdotes about family psychoeducation treatment and along the way mentions a number of resources for people who are interested in learning more about how to do family psychoeducation. And now on to the interview with Carol Anderson about family psychoeducation.
Interview
Jonathan Singer: Well Carol thanks so much for being here today and talking about family psychoeducation. First question, what is family psychoeducation?
Carol Anderson: Family psychoeducation is a research-based model that provides information to families about the illness and how to manage it in the context of a connected careful relationship and a follow up on how to implement the principles that people have been told about. Now, that’s my definition. There are a lot of people who might disagree because it's come to mean a lot of different things to different people but that’s I think the essence of it.
Jonathan Singer: So, what are some of the other things that psychoeducation or family psychoeducation has come to mean?
Carol Anderson: Well, some people think that if you just provide information to a family or patient, you know, that’s psychoeducation. That’s information and that’s important to provide information. I think it really helps people to connect and if they understand a little bit about what they're dealing with and all but that’s a limited view of what can be accomplished through doing a much more detailed involvement with the family.
Jonathan Singer: So, you're saying that if I have a family come to see me and it's the first session and I provide them some information about ADHD or schizophrenia or some other mental illness that that’s not psychoeducation, that’s providing information about a disorder.
Carol Anderson: I would say that and I would say that’s a good idea and good treatment but you need to know what people are coping with before you provide them with the information in my view because you want to set up a situation where they can hear what you have to say and if they don’t understand that you know what it's all about, they're going to listen in the same way and they are going to be able to accept some of the ideas because they’ve been struggling with probably a problem for a long time and they think they know more than you do about it some ways. So, you want to set it up so that you can tell them this is what you’ve probably been dealing with and this is why. So, it's a really important component of explaining illnesses and that’s part of the research base. Psychoeducation was created based on research that told us about this particular mental illness. In our case, it was schizophrenia and the normal natural things patients and families try to do to cope with schizophrenia are not the helpful things and so we're not saying that the family is disturbed but we're saying that what you and I would naturally do to try to help someone with a mental illness is not what they need.
Jonathan Singer: That’s really interesting. So, what were some of the things family members were doing with good intentions that were actually not being helpful?
Carol Anderson: Well, initially when you begin to see symptoms develop, you might try to convince someone it's not true, you know if someone is having hallucinations or delusions. You know that’s really not true. People are not trying to get you or people are not talking to you and through your teeth and some of the strange ideas that sometimes mentally ill people have or they might try to rally around the patient and spend a lot of time and care with them and these are patients who are vulnerable to stimulation so that in fact could make things more difficult for them. So, there are all kinds of natural responses that people have to illness and you would do that with a physical illness. You try to be there with them and try to help them all the time. And patients with schizophrenia for instance need time away, need not to be having people close in on them. When we found out some of that research that led us to develop the model, in a way that provided respite for both the patient and for the family in terms of intensity.
Jonathan Singer: So, when you say it's research-based, you're saying that you discovered some things about the way families interacted with family members who had schizophrenia and you found that some of these weren’t helpful and then you were able to find out what things were helpful.
Carol Anderson: Well, actually we based it on a lot of other people’s research when we started. Later, we could say some things are our own. It's been clear for quite a few years with various research projects that patients probably have some basic biological vulnerability to stress but then stress is a problem in exacerbating that vulnerability. And so the kind of models that had been done up until that time, treatment models and family models, were too intense. So, that’s part of the research base that I’m talking about. The Brown, Birley and Wing work out of England when they found that expressed emotion was difficult for patients and prompted relapse. It made so much sense when you understood that to try to do it differently.
Jonathan Singer: And what you're talking about is the diathesis-stress model.
Carol Anderson: Right.
Jonathan Singer: Okay.
Carol Anderson: Right. Some people call it the stress-diathesis model. Some people call it the stress vulnerability model but that’s basically the theory on which this all is based.
Jonathan Singer: You’ve been talking about when we developed this model, who’s the we and how did family psychoeducation developed?
Carol Anderson: Well, it developed in about 1978 I think we got the grant to do it. Gerry Hogarty who is a long-term psychotherapy of schizophrenia researcher and other interventions, medication interventions and all came to me with the article by Brown, Birley and Wing and knew I was interested in families and he said I'd like to do a comparative study of individual treatment for schizophrenia and the family model and if you could create for me a family model based on this information, we could really do a terrific project. Actually, he told me I could be the queen mother of schizophrenia and I read the article and I got really excited because I had pretty much decided that family therapy for schizophrenia was not a good idea because it tended to make people feel worse. So, we developed – I mainly developed the model and then Gerry did all the research on it and we did it for about eight years and had some really good results that those people who got family psychoeducation did better than those that got individual treatment and if they got both social skills training for the patient and family treatment, we virtually had almost no relapses in a long period of time which was very new at that time.
Jonathan Singer: That’s remarkable and just for our listeners who might not know what a relapse is, could you define what relapse means in this context?
Carol Anderson: Sure. It meant an acute exacerbation of the illness and a re-admission to a hospital. So, you would have people have an acute illness, we usually pick them up, the research pick them up during an acute episode. Some of them were people who had their first episode. Some of them had been ill for 25 years. They would be randomly assigned to family psychoeducation, social skills training, both or just medication maintenance. All of them got medication and that’s the group we compared over time.
Jonathan Singer: This is an approach to treatment that involves the family and it also involves medication–
Carol Anderson: Yes, it does.
Jonathan Singer: – which I know is – it can be a little bit controversial for some family therapist to say let's medicate one person in a system because then we're picking out one person in a system as opposed to addressing the whole system.
Carol Anderson: This was extremely controversial to family therapists when it started in the late ‘70s and in fact some of my colleagues accused me of selling out to the medical model. But to look at the family as the only potential cause of distress which was what a lot of the family models are based on in those days is rather simplistic. I mean, there are family factors that can help and there are family factors that can exacerbate the problems–
Jonathan Singer: Mm-hmm.
Carol Anderson: – and the notion that there was a biological vulnerability was controversial but it makes so much sense. I mean, we know with any illness it causes a stress on the family and the illness may be totally physical and still it would require a different kind of intervention. So, it was a problem and I think it might still be a problem in some family models that and some family therapists who have not been trained and who have not seen. You know, there are PET scans that show that the brains of these patients are different and that they, you know, there is plenty of evidence that they have vulnerabilities that run in families, etc. Of course, there could be other explanations for that too I’m sure but, but I think that it's really important to not close our minds to various things that influences the lives of patients whether they be the kinds of things we do to them, not just the family does to them but treatment settings that are very intense or difficult for these patients.
Jonathan Singer: Carol you said that Gerry Hogarty gave you an article and said, you know, if you can develop a model out of this then we can get this great project going, how did you develop family psychoeducation out of this article?
Carol Anderson: Well, to be perfectly honest, it wasn’t just out of the article. I mean, I had been a family therapist for about 20 years so I knew family models and I knew that there were things that fit with that article. What the article told me was that high intensity was not good for these people with this disorder. What that told me is okay, well let's try a structural intervention and it is highly structural are people with psychoeducation.
Jonathan Singer: And when you say structural, what do you mean?
Carol Anderson: Structural family therapy focusing on the importance of boundaries, generational boundaries, interpersonal boundaries and how those influence, you know, the functioning of the family. I also had a long experience dealing with families and hearing their stories about what they had been coping with and how hard it was for them. So, it's very sympathetic to what they had been managing over time. And I have this belief that they needed to know that. They needed to know that I understood how difficult it was before I gave any advice about this structure business and, you know, decreasing intensity or else they were going to say, you know, you just don’t understand.
So, the model turned into four – well actually in the end five phases. The first phase was connecting and during the connecting phase, we spend a lot of time listening to what they’ve been through, talking about how we knew other people had been through this, how hard it was, you know, what are the things they probably tried and haven't worked, etc., that kind of thing of the connecting phase. The second phase was the most exciting phase and that was the survival skills workshop and that was a day long workshop that we spent with could be anywhere from three to six families telling them everything that we knew and we would talk about you know the symptoms of the illness, the potential causes of the illness, what happens to people when they get the illness, what's medication all about, what goes on in the brain, what's the public experience of schizophrenia, in other words, what do they see when they see these symptoms, what's going on inside the patient when that happens, how the patient is feeling and thinking.
Then we spent – that was pretty much the morning and then we spent the afternoon telling them how you manage that and what was that going to do for them. And I have to say, you know, I've been in this field now for, I hesitate to say 40-some years, it always was the most exciting thing that I ever did with patients because families would come in and they would be skeptical and concerned and thinking what am I doing here. You probably are going to blame me because most of the families at that time were blamed for the mental illness and you know I’m not interested in this and by the end of the day, they were transformed. My God, they had so much more understanding for the patient to think I can just now see I've been so angry at him because he couldn’t get a hold of himself and now I can see what he must have been going through or what she must have been going through or you know now I can understand. I've never encouraged them to stay on their medication because they always looked kind of like zombies. Sometimes they were overmedicated and now I can see that, you know, when you tell me that the medication stays in his system for three months after he’s gone off of it, I never connected the relapse with stopping the medication but now I can see that. In fact, yes, he did relapse three months later and isn't that something and rather – so we have set up situations where we would work together against the illness and for the patient.
Jonathan Singer: And so–
Carol Anderson: Oh, I didn’t – I’m sorry.
Jonathan Singer: No, no, go ahead, go ahead.
Carol Anderson: After that though, because a lot of people stop there and I think that’s not enough.
Jonathan Singer: You mean they stopped after the second phase.
Carol Anderson: After the workshop.
Jonathan Singer: After the workshop, okay.
Carol Anderson: So and then there are a couple more phases. The next phase is what we called re-entry because they would leave the hospital or if they hadn’t been in the hospital they would be – we’d try to apply the principles that we have taught them in the workshop to how they're going to survive in everyday life.
Jonathan Singer: Now, let me just ask a quick question–
Carol Anderson: Okay.
Jonathan Singer: – so the first phase is this with the person with schizophrenia and the second phase is with the family without the person or is everybody together all at the same time?
Carol Anderson: Good question. In our model, the first phase was without the patient. And that was not because the patient didn’t have a right to hear or be involved in that but when we pick them up, they were usually – the patient was acutely psychotic and wouldn’t have been able to tolerate sitting and discussing this and we also thought the family needed to let off a little steam about what they’ve been going through. So, we would try to connect with the patient but we would do that separately. So, there’d be separate sessions with the patient and with the family and we would concentrate on the family’s needs at that time. The workshop and we try to do that early on too, so we didn’t think it would be too good to have the patient therapy because a workshop lasts about six to eight hours depending on the group of families and what they had to say. So, the patient wasn’t involved in that and the patient was given that information separately in much smaller doses.
Jonathan Singer: And it sounds like one of the reasons is because typically it's – the patient was being stabilized and prior to that–
Carol Anderson: Right.
Jonathan Singer: – they would have had a very hard time with all the stimuli and all the information, the intensity–
Carol Anderson: Right.
Jonathan Singer: – of those first two phases.
Carol Anderson: That’s correct and I’m just aware that we're talking about the patient the patient. You know, that’s old language and today–
Jonathan Singer: That old language, yes.
Carol Anderson: – we don’t like to talk about that–
Jonathan Singer: Uh-huh.
Carol Anderson: – and then it went to consumer and now we talk about the individual with the mental illness.
Jonathan Singer: Right.
Carol Anderson: And I’m just old enough that it's hard for me to make the switch but I really support that (especially).
Jonathan Singer: Okay. Well, from now on we'll talk about the individual with the mental illness.
Carol Anderson: Okay.
Jonathan Singer: So, you have those first two phases and then there's the third phase.
Carol Anderson: Re-entry and basically that was applying the principles to surviving in the community but doing it extremely slowly because what we do know is the first three months after an episode is the highest risk time for another episode so that you want to create a stable period of time where they can kind of get their selves together. During that time, the other thing that is a serious problem for both the patient and the family is dealing with negative symptoms of schizophrenia. Now, the positive symptoms are the delusions, the hallucinations, the thought problems, etc. But even more difficult for families to tolerate are the negative symptoms when they become a motivated, disinterested, they sleep excessively and that goes on sometimes for a long time. And so what we would do during that time is we try to keep them moving, try to keep them functioning, move towards having a social life, towards being able to work but generally speaking, we wouldn’t push on that until we had six months of stability and when we had six months of stability then we would get much more actively involved in what we call phase four of getting them out into the community.
Jonathan Singer: So, phase three, re-entry was really – could be six months.
Carol Anderson: Could be six months. I can remember one case, it took two years.
Jonathan Singer: Really.
Carol Anderson: The young man just could not get past the excessive sleep and they tried various medications because they thought he was overmedicated but it was a period of time that he just didn’t come to life and then one day in treatment, he made a joke and we were so thrilled because humor is one of the last things to return often and right after that he was able to go to a local rehab and he started having friends again. It was time for great celebration among the team.
Jonathan Singer: I've never thought about humor being one of the last things to return but humor requires that you understand sort of the way things are and be able to twist them and if you’ve not had a good grasp on what reality is–
Carol Anderson: It's hard.
Jonathan Singer: – you can't make that twist, yeah.
Carol Anderson: And nothing seems too funny.
Jonathan Singer: Right.
Carol Anderson: Now not to say that there aren't some individuals that even throughout have a sense of humor–
Jonathan Singer: Mm-hmm.
Carol Anderson: – but it's rare.
Jonathan Singer: Mm-hmm. Mm-hmm.
Carol Anderson: Some of them say funny things, unwittingly humorous to the rest of us but–
Jonathan Singer: Right.
Carol Anderson: – they are not – I'll tell you an example, you may want to edit this out but we were having a multiple family group because we did do that occasionally and it was during the time John Hinckley shot President–
Jonathan Singer: Reagan.
Carol Anderson: – Reagan and people always got very concerned about these kinds of things because it added to the stigma of mental illness and the fear people had of people who are mentally ill. One of the family members in the group said well yeah, what would you call John Hinckley and one of the patients said I call him a bad shot.
Jonathan Singer: And I could see in the context of treatment that that could be very funny obviously if you're, you know, just out in public and there's no contacts. It could be very offensive but–
Carol Anderson: Yes.
Jonathan Singer: – something like that really says oh, I thought you were going to be more concrete.
Carol Anderson: (Referring) was he schizophrenic or not.
Jonathan Singer: So, you’ve talked about four phases or you’ve talked about the three phases then what happen next?
Carol Anderson: Well throughout even during the third phase, we do very small steps. You never give up. You never stop pushing because you don’t want them to sink into this negative, you know, process where they're not doing anything with their lives because that can be very destructive in the long run, too. But we ramp up the phase in the fourth phase and we really start focusing on social context which sometimes is very difficult and being able to work or go to school. Throughout the whole process, our team was always one change at a time. If they were working on social contacts, we wouldn’t work on work. If they were managing certain family events like a wedding or whatever which is often very upsetting even if they're positive events then we wouldn’t initiate, you know, social or work contact. So, there would be one change at a time and in the fourth phase we would do a much more focused approach to functioning.
Jonathan Singer: And what would you do to focus it even more in the fourth phase?
Carol Anderson: Well, for instance, that’s when we might institute vocational rehabilitation.
Jonathan Singer: Okay.
Carol Anderson: They might start going to a program like that. We might give them assignments to go out and meet people, go to a drop in center. We might help them develop certain kinds of skills. It was always focusing on what they wanted to do next. We would offer them the possibility would you like to focus on social things, would you like to focus on work, etc. But we would let them make that choice and sometimes they chose the one that was most difficult and sometimes they chose the one – this will be a little easier for me, I'd like to start there.
Jonathan Singer: So, this really was acknowledging how far this person had come from the time they started the psychoeducation too and now you're making choices about what it is you want to do that you feel would be best for your ongoing improvement.
Carol Anderson: That’s right.
Jonathan Singer: Okay. Now, you also mentioned that there was a fifth, that you added a fifth phase.
Carol Anderson: Yes. Well, we started distinguishing between four and five in a way we hadn’t initially. What we said with the fifth phase was we would do family therapy about traditional family issues if they wanted it, you know, now you’ve got the person is functioning, there is, you know, there are other issues in the family that might be marital issues between the parents. Very often they’d cope with a lot of stress over time and it's had a bad effect on the marriage. The person may want to move out and there is some strain about that. So, the kind of things family therapists will do and so we would offer that. I have to say that not very many people took us up on it. People would say this has been wonderful. This is great. I don’t want to stir up anything else. Leave us alone, you know, we'll come every six months and tell you how things are going. But it was a distinct phase and there were a few that said yeah, we really need to look at our relationships now.
Jonathan Singer: So, the fifth phase was really an opportunity to do what people had started to do years ago but because they hadn’t done the first four phases that you’ve developed in psychoeducation, they couldn’t actually get to the point where they can do family therapy effectively.
Carol Anderson: That would be my view on it. I mean, our basic assumption is not that families cause schizophrenia and there was a long history that family, you know, people believing families did cause schizophrenia and that had to do with family communications because you will see sometimes that the communications in these families are a little odd but if you're living with someone who doesn’t know what reality is for a long period of time, your communications might get a little odd also. So, we thought that when you have that kind of stability, they have the right as anyone else does to try to improve relationships and improve their functioning and so traditional family therapy was then to us appropriate if they wanted it. But we all have a choice of whether we want therapy. If we're functioning we don’t need therapy unless we want it.
Jonathan Singer: That’s right. Family psychoeducation that way that you and your colleagues developed it was originally of four-stage and eventually a five-stage process but it was something that could last for a couple of years.
Carol Anderson: Absolutely.
Jonathan Singer: So, it's very different than, you know, hi my name is Jonathan. Thanks for coming in. Here’s a pamphlet about schizophrenia. You might want to read this and now we'll get on with our therapy.
Carol Anderson: I'd say that’s quite, quite a bit different yes.
Jonathan Singer: Quite a bit different, okay.
Carol Anderson: Well, you have to understand that this schizophrenia is a chronic illness and people are going to be coping with it for a long time. Twenty percent of the people who get this disorder never have another episode and that’s terrific. But nobody can predict who those people are. You can't tell when you start out who they are. So, you have to be prepared to stick with them for a while. It's only fair.
Jonathan Singer: Carol, I suspect that there are social workers out there, students, maybe even educators who are listening to this podcast and thinking well, this is a little different than what I thought psychoeducation was. It sounds like something I would want to use with the clients that are on my caseload, so how would somebody get training in psychoeducation? How would somebody be able to do these four or five stages that you talked about?
Carol Anderson: Well, specifically in our model we wrote a book that is in essence a cookbook. It tells you exactly what to do. It tells you how to connect, how to do a workshop, you know, how to get people back to work, how to deal with the entries and that’s, that’s still available. It's called Schizophrenia and the Family, Guilford Press, little commercial here–
Jonathan Singer: Okay. Well, we'll put a link on the website.
Carol Anderson: Okay. Most people learn to do psychoeducation through workshops. I know when I first did this there were a ton of workshops that I get around the country and even in Asia, South America and Europe. There are still people who are doing workshops like Bill McFarlane. I believe he’s still active in that way and some of his staff. On the (SAMS) website, there is some information about psychoeducation and how to do it and very concrete ideas about it. Unfortunately, I don’t think that it's a core part of most masters programs or doctoral programs. I think it's mostly learned by people who are interested and who get excited about the ideas and get excited about that notion of having a different kind of relationship with families and patients because it is very different and it is much more collaborative and more real. I think NAMI also probably puts out some things using the same principles. I’m not sure they would call it psychoeducation. But I think they do have people who write on this and who might also provide training. The truth of the matter is the model is just common sense once you accept the basic principles. Once you understand that these are people who are going to be vulnerable to stimulation then you need to find ways even though it's not normal for people to not be overstimulated and need to be able to manage very concrete steps, I mean, it's so social work particularly for social work it's the ecological view. It's, you know, fitting lots of things together. It offers concrete help. I mean, it is just – it's so natural–
Jonathan Singer: Mm-hmm.
Carol Anderson: – and I don’t know why everyone doesn’t do it if they're working with this population.
Jonathan Singer: I mean you really start where the client is.
Carol Anderson: Exactly.
Jonathan Singer: Yeah.
Carol Anderson: Exactly.
Jonathan Singer: Yeah. Now, speaking of starting where the client is, I know that you developed this model working with families where there was a member with schizophrenia but can you use psychoeducation, conceptually can it be used with people with different mental illnesses and has it been studied for use with people with different mental illnesses?
Carol Anderson: It absolutely could be used for people with any illness. I would say even certain physical illnesses, chronic physical illnesses because it would be helpful to go through the same kind of stage process, maybe not quite as long as the way we did it. There is research and a book on doing this kind of a model with bipolar disorder published by David Miklowitz and you may want to put a contact to that one, too.
Jonathan Singer: We'll put the link on the website, yeah.
Carol Anderson: And I think there are a lot of publications about using this with various childhood disorders, attention deficit, you know, those kinds of things. I don’t know if they’ve done specific research and I don’t know if they’ve used our version of you know the structure of what psychoeducation should look like but they call it psychoeducation in many cases and I don’t think it's just handing a pamphlet as you talked about. I think it is more involved than that. So, there are all kinds of things that it could be relevant for. I’m not saying it's the aspirin for every problem in the world but dealing with specific illnesses be they physical or mental, I think it is a pretty good structure for how you do your treatment.
Jonathan Singer: And it sounds like particularly with illnesses that have some amount of longevity.
Carol Anderson: I don’t recommend it for the flu.
Jonathan Singer: Right. It's pretty involved for the flu. Yes. Psychoeducation is considered a family therapy, can you talk about how it's similar to and different from some of the other traditional family therapy models like the experiential models of Carl Whitaker, Virginia Satir or Jay Haley’s strategic family therapy?
Carol Anderson: I can talk a little bit about that. When I first started doing family therapy which would have been about 196-, I hesitate to say this, ’67 or so–
Jonathan Singer: Mm-hmm.
Carol Anderson: I was about 12 at the time. The major models were experiential. Virginia Satir and I think Nathan Ackerman were the only books out there. What you did was you brought families into the room and you help them to express their feelings to one another, to be more, you know, involved in communicating with one another and my experience at that time was that was helpful to a lot people but it sure wasn’t helpful to people who had a psychosis in their family. It's the whole expressiveness of a lot of the models that was difficult for these kinds of patients so that, that’s a major difference in terms of psychoeducation really not encouraging emotional expressions, not encouraging talk about very complex issues. For instance, talking about things that are intense to most of us at any time, religion, politics, our family, most difficult issues about sexuality or all those kinds of things, they're just not a part of the whole first four phases of psychoeducation and that’s where a lot of family therapy is focused.
The other issue with many of the family therapy models is it does assume that the family is the cause of whatever disorder or whatever symptom is being presented by “the identified patient.” And so the early models, it just, they just don’t work and they're very different. Now, structural though is a very short term model. It is highly focused on specific tasks and we did incorporate a lot of that. There isn't that much difference. And even the Bowen model focuses a lot on decreasing anxiety and we certainly focused on that as well although I wouldn’t describe this because we don’t do a historical approach or family of origin approach. I wouldn’t describe it as a Bowen model but there are some compatibilities with that. I think that people could modify the structure of this model to include some of those other things. I just wouldn’t recommend it in the early phases because I think the most important thing is to get this person out of hospitals, functioning and making it in the community.
Jonathan Singer: Carol, you’ve given us a background about how psychoeducation developed, what the steps are for psychoeducation, how it's similar to and different from some existing family therapy models and of course you’ve given some examples of what treatment looks like, I was wondering if you could tell us about maybe one family that went all the way from the first stage to the fifth in psychoeducation and talk a little bit about what that process was like.
Carol Anderson: Sure. A case I’m thinking of is a young man who had been ill for about seven years who had been very seriously ill and had very few good times during those seven years and he was – when we picked him up, he was at the point where he was homeless, still in contact with his family but he was homeless. He was ill-kempt. He had not brushed his teeth in seven years or showered. Well, he might have showered some time during that seven years but the teeth he hadn’t touched in seven years and the family wanted to take him back home because they were worried about the safety of him on the streets. I mean, lots of bad things happen to these patients when they're out there. So, we began focusing on small tasks which is part of the theme of the model, small changes. We want to build in experiences of success. So, the first task we gave as a homework task was that sometime between the session that we were in and the first – the next session we were going to have that he would brush his teeth once.
Jonathan Singer: Really. So, how did you come up with that task?
Carol Anderson: Well, that task was because he was going back home and his family found it very difficult to have this ill-kempt, smelly person around and that, you know, they were concerned about that but, you know, it was something doable also. It was something that we could take on and we thought we could get some success in because we wanted to build confidence and you don’t start with anything that – not the most crucial issues like his psychotic thoughts but the issues that you can start getting the person prepared to be a participating member of the family and of the community.
Jonathan Singer: So, this was, this was after you had done the first stage and the second–
Carol Anderson: And the workshop.
Jonathan Singer: – and the workshop and the second stage. So, this is the third stage–
Carol Anderson: Right.
Jonathan Singer: – and the family came to you and said we want him home, we care about him but we got to be honest, it's a little distressing and disturbing to us how badly he smells and his teeth. And so you said okay, well this is something that he could probably be successful at and so that was the first task.
Carol Anderson: That was the first task and he did it and that gradually – one task built upon another until he was looking more socially acceptable and in the meantime, the family is feeling better about him. There's less pressure. They're doing less to intrude upon him. They're letting it be up to him and he reports to us in the sessions, etc. And then gradually we built on him going out of the house more and having some kind of social contacts. We're talking over, you know, months and months of him getting to the point where he felt comfortable going out, getting to the point of having relationships sometimes with other patients but then gradually with extended family and other people in the community. Eventually, he first got a job sweeping floors in a restaurant. There's an art to getting people who are bright aside from their mental illness to see that it's relevant to have a job like that. But the way we present those kinds of things is you need to get used to having a job, to having responsibilities, to getting up in the morning, etc. and so we're building skills that will get you to the kind of job or life you would like to have.
So, eventually he got a better job, eventually he went to community college and graduated from community college, got a girlfriend and at that point, things were stable for so long that we offered the family the opportunity to talk about other issues and the parents chose that time to say we’d like to work on our relationship without him because we've spent so many years just staying on top of this whole problem of mental illness that we don’t even know each other anymore. And so they started talking about their relationship and getting reacquainted. We assigned them going out on dates and all and they did that. And it was a wonderful experience for us to see it could get that far too because not everybody chose to go the family road at the end.
Jonathan Singer: And so the parents working on their own issues, this was the fifth phase that you're talking about that most families did not take you up on.
Carol Anderson: Right. Right. Right.
Jonathan Singer: Okay.
Carol Anderson: So, it was a wonderful success case and I think that not all of them were able to go to college. I mean, obviously there are patients that don’t do that well and there are patients who are always going to be a little odd or off by themselves but many of them as we know from other people’s research and long term 20-year follow ups on this disorder that you would not know that they had ever had a mental illness. So, it does tend to get better over time if you can prevent the deskilling and the negative effects of hospitalization long term.
Jonathan Singer: Well Carol thanks so much for spending the time to talk to us today about family psychoeducation. It was a pleasure for me.
Carol Anderson: I enjoyed it too actually.
Jonathan Singer: All right. Great. Thanks so much.
Carol Anderson: Bye.
--End--
References
- Anderson, C. M., Hogarty, G. E., & Reiss, D. J. (1986). Schizophrenia and the family: A practitioner's guide to psychoeducation and management. New York: The Guilford Press.
- Brown, G. W., Birley, J. L., & Wing, J. K. (1972) Influence of family life on the course of schizophrenic disorders: A replication. British Journal of Psychiatry, 121(562) 241-258.
- McFarlane, W. R. (2003) Family psychoeducation and schizophrenia: A review of the literature. Journal of Marital & Family Therapy, 29(2), 223-245.
- Miklowitz, D. J. (2007) The role of the family in the course and treatment of bipolar disorder. Current Directions in Psychological Science, 16(4), 192-196.
- Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Suddath, R. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60(9), 904-912.
Pekkala E, Merinder L. (2002). Psychoeducation for schizophrenia. Cochrane Database of Systematic Reviews, 2. Art. No.: CD002831. http://dx.doi.org/10.1002/14651858.CD002831.
- As the federal agency responsible for promoting the quality, availability, and accessibility of services for people with mental illness, CMHS is responsible for identifying treatments for mental illness that work. The materials in this resource kit document the evidence for the effectiveness of Family Psychoeducation and provide detailed information to help communities to implement the practice in real world settings.
APA (6th ed) citation for this podcast: Singer, J. B. (Host). (2007, October 24). Family Psychoeducation: Interview with Carol Anderson, Ph.D. [Episode 27]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/10/family-psychoeducation-interview-with.html
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