Psychoeducational family approach with family education (Ran)

Psychoeducational Family Intervention in Chengdu, China

Maosheng Ran., MD., PhD

Associate Professor

College of Professional Studies, University of Guam

Summary

Family interventions for schizophrenia in the West may not be completely appropriate within the Chinese context without some modification to accommodate widespread low education and poor economic status. Psychoeducational family intervention in Chengdu was a cooperation study between West China University of Medical Sciences and Bureau of Public Health of Xinjin County and Xinjin Mental Hospital. In this study, the focus of the psychoeducational family intervention is on three elements: an education programme including family session and village broadcast, multiple family workshops, and crisis intervention.

Family Sessions

The psychoeducational family intervention was mainly conducted through family sessions. Family members present for the sessions included the person with schizophrenia and his/her key relatives. Key relatives were defined as the main carers and/or the relatives who had the most contact with the individual with schizophrenia. Each visit was conducted in the family home, once a month for 9 months. At least two doctors, one psychiatrist and one village doctor, conducted the family sessions which lasted 1.5 - 3.0 hours. During the visit the psychiatrist would discuss the situation with the family member experiencing schizophrenia and the other family members who were present. The educational component would then be implemented.

The content of the family education component included: a) definitions of a schizophrenic disorder; b) a description of the various symptoms; c) comprehensive basis of the illness; d) general prognosis of the illness; e) treatment recommendations concerning pharmacotherapy; and f) long-term management of the illness including relapse prevention and social functioning rehabilitation. Language used during the visits would be leveled to fit with the patient and family to promote better understanding. Helping the families to find non-judgmental and non-critical coping strategies were also emphasized. During the first two months, local broadcasting, once two weeks for 2 months, was used to disseminate information about the project and provide basic knowledge of mental illness.

Multiple Family Workshop

Multiple Family Workshops were also conducted as part of this research. Multiple family workshops were held every three months in a large, comfortable room in one village. Each workshop included 6 to 12 relatives and one psychiatrist and one village doctor. One of the aims of the workshop was to prevent of the families from developing a sense of being blamed for the development of the illness and to decrease the attrition rate. The rules of the workshop were: (a) key relatives were expected to attend each meeting, (b) families should attempt to share their difficulties, and (c) family members should feel free to interact with members of other families.

In the workshop, the therapists acted as facilitators. Topics included medication usage, detecting relapse, controlling violence, marriage, dealing with stigma, and mental health laws. All the relatives were encouraged to share their problems and their solutions. The purpose was to enable them to support each other, learn about new coping strategies, and help them try a different approach at home. The focus of the workshop was on guiding and sharing their experiences related to potential or actual difficulties. The workshop discussion was focused on practical aspects of living, routine work in village and family, management of patient with schizophrenia, or expanding social networks. This involved strategies to reduce family tension, deal with medication non-compliance and avoiding or attenuating stress.

Crisis Intervention

Crisis intervention was conducted whenever required (e.g. crisis/emergencies). Primarily, the psychiatrists and trained village doctors conducted crisis intervention. These emergencies include acute side-effects of drug, suicidal ideation, suicide attempts, and aggressive or destructive behavior. In this study, the relatives were also trained to seek help in these situations.

Different Phases

The process of psychoeducational family intervention was divided into three phases. Each phase had a different focus as follow.

Phase I Connecting with Families

This phase concentrated on establishing a supportive relationship with the patients and their relatives. During this phase, patients were assessed, relatives received basic knowledge of the illness and the entire family began to understand the illness and its symptoms. Families were taught how to use therapeutic resources and when to seek professional help. This phase usually lasted for two months.

Phase II Improving Skills

In this phase, detailed information on the illness and its management was provided and families were assisted to form a support network. The relatives and the patient were educated about the treatment and prevention. Comprehensive discussion is conducted about the nature of schizophrenia, as well as drug and psychosocial interventions. Families were taught specific family management strategies for stress reduction and coping with the illness, and encouraged to attenuate their expectations for full recovery and functioning of the patients. In general, this phase lasted for two months.

Phase III Maintenance

The family management strategies are individualized and applied to each family’s specific concerns and problems. Families were trained to cope with specific symptoms and how to improve the patients’ social functioning. Avoiding family conflict was also emphasized. Patients were encouraged to participate in the family sessions, engage in social activities, and expand their social networks. Patients were also assisted in activities of daily living. Reinforcement is provided for small successes. As the patient became less withdrawn, more ambitious tasks were assigned to facilitate a return to appropriate work and social functioning. Expectations for substantial changes in the patients’ social status were kept low and families were encouraged in their persistent efforts.

Drug Treatment

Owing to the poor availability, access and compliance of medical services to persons with schizophrenia in China, the choice of the long-acting depot neuroleptic medications was a viable option. Thus, during the period of psychoeducational family intervention, the lowest dose of long-term depot with the fewest side effects was also used in this study. The drug treatment consisted of long-term injection of haloperidol decanoate (50mg-125mg / month) and oral medication (penfluridol, 20mg-40mg / week). Dosage was determined by the trained psychiatrists and set at lowest effective dose level. By prescribing the simplest dose schedule polypharmacy is avoided.

Materials for Intervention

The manual used in this study is in Chinese. The book of ‘Family-Based Mental Health Care in Rural China’ and a few articles (see References) will be helpful for further understanding of this study.

Guidelines for Effective Family Intervention

  1. A comprehensive individualized assessment of client’s need should be done
  2. It is important to establish a collaborative, respectful, and therapeutic alliance between professionals who conduct the intervention and patients and their relatives
  3. It is important to use a family systems approach that focuses on the family unit as a whole, as well as individual family members
  4. Education should be combined with other psychosocial approaches
  5. Education should be tailored to the characteristics of the population
  6. Education should be continuous throughout the period of contact with patients and their relatives
  7. The intervention should be maintained over an extended period of time
  8. Families should be encouraged to find ways of coping with the difficulties in a nonjudgmental and noncritical manner
  9. Training and supervision of the professionals who conduct the intervention are vital for a successful intervention
  10. The interventions should take place in collaboration with other interventions, such as pharmacotherapy, vocational rehabilitation, case management, and assertive community treatment
  11. Maintaining medication treatment is an important aim of intervention, especially where people suffering from schizophrenia have difficulty accessing basic drugs
  12. Medications should be individually tailored, simple, and effective
  13. Developing realistic family expectations and maintaining hope for the individual’s recovery are important
  14. The intervention should improve communication between people with schizophrenia and their family members, and expand the social network of the person with schizophrenia.
  15. The intervention should be acceptable culturally and be congruent with the needs of the families

Contact Information for Further Information

Mao-Sheng Ran., MD., PhD., Associate Professor, School of Nursing, Social Work and Health Sciences, College of Professional Studies, University of Guam, Mangilao, Guam 96923, USA. E-Mail: ranmaosh@yahoo.com.

References

Leff JP, Kuipers L, Berkowitz R, Eberlein-Fries R, Sturgeon D. A controlled trial of social intervention in schizophrenia families. British Journal of Psychiatry 1982; 141: 121-134.

McFarlane WR. Multiple family groups and the treatment of schizophrenia. In: MI Herz, SJ Keith, JP Docherty, (Eds.), Psychosocial Treatment of Schizophrenia. 1990, pp. 167-189. New York: Elsevier.

Ran MS, Xiang MZ, Liu XH, Li SG, Xie YH, Zhou SD. The effectiveness of haloperidol decanoate for treating schizophrenia in a rural area. Shanghai Archives of Psychiatry 1992; New 4(4): 251-253. (in Chinese)

Ran MS, Xiang MZ, Chan CLW, Leff J, Simpson P, Huang MS, Shan YH, Li SG. Effectiveness ofpsychoeducational intervention for rural Chinese families experiencing schizophrenia: A randomised controlled trial. Social Psychiatry and Psychiatric Epidemiology 2003; 38: 69-75.

Ran MS, Xiang MZ, Simpson P, Chan CLW. Family-Based Mental Health Care In Rural China.Hong Kong: Hong KongUniversity Press, 2005.

Wing JK, Olsen R. (Eds.). Community care for the mentally disabled. Oxford: Oxford University Press, 1979.

Xiang MZ, Ran MS, Li SG. A controlled evaluation of psychoeducational family intervention in a rural Chinese community. British Journal of Psychiatry 1994; 165: 544-548.