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How we know that FamilyPsychoeducation is effectiveWho benefits most from FamilyPsychoeducation?FPE is based on research that shows thatconsumers and families who participated in thecomponents of the evidence-based model had 20to 50 percent fewer relapses and rehospitalizationsthan those who received standard individualservices over 2 years (Penn & Mueser, 1996; Dixon& Lehman, 1995; Lam, Knipers, & Leff, 1993;Falloon et al., 1999). Those at the higher end of thisrange participated for more than 3 months.The greatest amount of research has shown benefitsfor consumers with schizophrenic disorders andtheir families (Dixon et al., 2001). Studies also showpromising results for the following illnesses:Studies also show that FPE improved family wellbeing (Dixon et al., 2001). Families reported agreater knowledge of serious mental illnesses;a decrease in feeling confused, stressed, andisolated; and reduced medical illnesses and useof medical care (Dyck, Hendryx, Short, Voss, &McFarlane, 2002).n Major depression—(Simoneau et al., 1999;FPE has been found to increase consumers’participation in vocational rehabilitation programs(Falloon & Pederson, 1985). Studies have shownemployment rate gains of two to four times baselinelevels, when combined with evidence-basedpractice Supported Employment (McFarlane,Dushay, Stastny, Deakins, & Link, 1996; McFarlaneet al., 1995; McFarlane et al., 2000).Studies show that the effectiveness of FPE doesnot differ depending on consumers’ age, gender,education-level, or severity of illness.Based on this significant evidence, treatmentguidelines recommend involving families inthe treatment process by offering the criticalingredients outlined in this evidence-based model(Lehman & Steinwachs, 1998; American PsychiatricAssociation, 1997; Weiden, Scheifler, McEvoy,Allen, & Ross., 1999).n England—(Leff, Kuipers, Berkowitz, & Sturgeon,n Bipolar disorder—(Clarkin, Carpenter, Hull,Wilner, & Glick, 1998; Miklowitz & Goldstein,1997; Moltz, 1993; Parikh et al., 1997; Miklowitzet al., 2000; Simoneau, Miklowitz, Richards,Saleem, & George, 1999);Emanuels-Zuurveen & Emmelkamp, 1997; Leffet al., 2000);n Obsessive-compulsive disorder—(Van Noppen,1999); andn Borderline personality disorder—(Gunderson,Berkowitz, & Ruizsancho,, 1997).This model has also been adapted and usedeffectively with a number of ethnic groups in avariety of settings in the United States. Studies havealso been conducted in the following countries:1985; Leff et al., 1990; Tarrier et al., 1989);n Spain—(Muela Martinez & Godoy Garcia, 2001;Montero, Gomez-Beneyto, Ruiz, Puche, &Adam, 1992; Tomaras et al., 2000);n Germany—(Wiedemann et al., 2001); andn China—(Xiong et al., 1994; Zhang, Wan, Li, &Phillips, 1994).Building Your Program5What Is Family Psychoeducation?

Although more replications are desirable, all theevidence to date suggests that the positive effectsof FPE generalize to nearly all major culturalpopulations: British, American, Australian, AfricanAmerican, Spanish or Latino, Scandinavianor Northern European, Chinese, and Japanese.However, anecdotally we know that culture andlanguage pose significant barriers to providingFPE in some populations and, in any case, requireculturally sensitive adaptations that must be furtherexplored empirically.Research shows that practitioners often askconsumers for permission to involve their familymembers during a crisis (Marshall & Solomon,2003). Asking for family involvement at thistime may raise suspicions for some consumers.Consequently, they may be more reluctantto identify supportive people. For this reason,modify your intake and assessment proceduresso that consumers are routinely told about the FPEprogram and are periodically asked if they would liketo involve someone supportive in their treatment.For more detail, see Set up referral proceduresunder Tips for Agency Administrators and FamilyIntervention Coordinators in this booklet.I s Family Psychoeducation for the family’sbenefit or for the consumer’s?If consumers do not wish to involve familymembers in their treatment, FPE practitionersshould respect their decision. If consumers do notgive permission to share confidential informationwith their families, FPE practitioners may stillrespond to families’ questions and concerns.Even the strictest interpretation of confidentialitypolicies does not prohibit receiving informationfrom families or giving them general informationabout serious mental illnesses and agency services(Bogart & Solomon, 1999; Zipple, Langle, Spaniol,& Fisher, 1997).FPE is for both consumers and families. Thegoal is to support recovery from serious mentalillnesses. The evidence-based model asks familymembers to help in that effort. Though it isdesigned to achieve clinical outcomes and recoverygoals for consumers, beneficial effects have beenfound for families as well. hat if consumers do not have familyWor do not want their families involved?If families want to learn more about serious mentalillnesses, FPE practitioners should direct themto local family organizations such as the NationalAlliance on Mental Illness (NAMI). Consumerswho are not interested in FPE may benefit fromother education and skills training programs thatare targeted specifically to consumers such asIllness Management and Recovery. For moreinformation, see the Illness Management andRecovery KIT.In FPE, the term family includes anyoneconsumers identify as being supportive in therecovery process. The broad definition emphasizesthat consumers choose whether to involve familyand whom to involve. FPE helps consumersdevelop or enhance their support networks.The evidence-based model has been found to workwell with consumers who are disengaged fromtheir families and have difficult treatment histories.Joining sessions give practitioners the opportunityto help consumers engage family members againin a constructive and supportive manner.What Is Family Psychoeducation?6Building Your Program

Where should FamilyPsychoeducation be provided?Is it cost effective?Implementing an FPE program has initial costsrelated to training and program development.However, studies show a low cost-benefit ratiorelated to savings from reduced hospital admissions,hospital days, and crisis intervention contacts(McFarlane, Dixon, Lukens, & Lucksted, 2003).The FPE multifamily group model was firstdeveloped in a partial hospital setting. Nearlyall of the controlled research on effectivenesshas been conducted in outpatient clinics andcommunity mental health centers. The extent towhich FPE can be successfully adapted to othertypes of agencies is unknown.Cost-benefit ratios vary by state. For example, inNew York, for every 1 in costs for FPE providedin a multifamily group format, a 34 savings inhospital costs occurred during the second year oftreatment (McFarlane, 2002). In a hospital settingin Maine, an average net savings occurred of 4,300per consumer each year over 2 years. Ratios of 1spent for this service to 10 in saved hospitalizationcosts were routinely achieved.FPE has been successfully implemented in bothurban and rural settings, as well as in mid-sizedcities and suburbs. For more information, seeThe Evidence in this KIT.Non-fiscal savings are achieved as complaints fromfamilies about services decrease and family supportfor the agency and the mental health authoritygrows. In many communities, this has translatedinto political support for funding for expandedand improved services.Building Your Program7What Is Family Psychoeducation?

Building Your ProgramTips for Mental Health AuthoritiesSuccessfully implementing evidence-based practices requires the leadershipand involvement of mental health authorities. This section discusses whymental health authorities should be involved in implementing FamilyPsychoeducation and the types of activities that mental health authoritiestypically undertake.Why should you be interested in Family Psychoeducation?The Family Psychoeducation (FPE) KITgives public mental health authorities aunique opportunity to improve clinicalservices for adults with serious mentalillnesses. Research has shown that FPEhas a consistent, positive impact on theBuilding Your Program9lives of consumers and their families.The FPE KIT gives you information andguidance for implementing this evidencebased practice in a comprehensive andeasy-to-use format.Tips for Mental Health Authorities

How can mental healthauthorities support FamilyPsychoeducation?Be Involved in Family PsychoeducationStep 1 Create a vision by clearly articulatingAs you read about FPE, you may think thatit sounds great but unaffordable. We want tochallenge that notion because mental healthsystems with limited resources are in the processof implementing FPE programs system-wide.These systems have visionaries who recognizedthe benefits of providing this evidence-basedpractice and who persisted in overcomingchallenges. We hope you are that visionaryfor your system.evidence-based practice principlesand goals. Designate a staff person tooversee your FPE initiative.Step 2 Form advisory groups to buildsupport, plan, and provide feedback foryour FPE initiative.Step 3 Establish program standardsthat support implementation. Makeadherence to those standards part oflicensing criteria.Implementing this evidence-based model takes aconsolidated effort by agency staff, mental healthauthorities, consumers, and families. However,for this initiative to be successful, mental healthauthorities must lead and be involved in developingFPE programs in local communities.Step 4 Address financial issues and alignincentives to support implementation.Step 5 Develop a training structure tailoredto the needs of different stakeholders.Step 6 Monitor fidelity and outcomesto maintain and sustain programeffectiveness.Tips for Mental Health Authorities10Building Your Program

Create a visionForm advisory groupsAgencies commonly set out to implementone program, but end up with somethingentirely different. Sometimes these variationsare intentional, but often they occur for thefollowing reasons:You can ensure that the FPE model is implementedappropriately if you contractually mandatethat stakeholder advisory groups guide theimplementation initiative. Your FPE initiativecan benefit in many ways from an advisory group.Among other things, an advisory group can helpyou do the following:n One administration starts an initiative andanother with a different vision and prioritiessubsequently assumes leadership.n Build internal and external support;n The model wasn’t clearly understood fromn Increase program visibility; andits inception.n Seek advice about ongoing planning efforts.n The staff drifted back to doing things in a waythat was more familiar and comfortable.Consider forming both local and state-level advisorygroups. State-level advisory groups may include thefollowing members:Articulating the vision that providing FPE helpsfamilies and consumers recover from mentalillnesses is essential for successfully implementingan FPE program. Place the FPE initiative inthe context of the larger recovery paradigm.Talk about how FPE programs help agenciesfulfill their mission—assisting consumers in theirrecovery process.n Representatives of state agencies that would beinvested in the initiative;n Leadership from implementing agencies; andn Representatives from consumer and familyadvocacy organizations.Local advisory groups can serve as liaisons betweenthe community and agencies that are implementingFPE programs. Community stakeholders who havean interest in the success of FPE programs includethe following:To ensure that your vision is clearly communicated,designate a staff person who has experience withthe evidence-based model to oversee your FPEinitiative. Some mental health authorities designatean office or staff with whom agencies may consultthroughout the process of building and sustainingtheir FPE programs. Designated staff may alsohave oversight responsibility for FPE programsacross the state.Building Your Programn Local consumer organizations;n Local family organizations;n Agency administrators; andn FPE practitioners.11Tips for Mental Health Authorities

Establish program standardsFacilitating your advisory groupFrom the beginning, lead your advisory groupsin understanding and articulating what FPEis and how it is going to be developed in yourmental health system. For training materials thatyou can use to help stakeholders develop a basicunderstanding of FPE, see Using Multimedia toIntroduce Your EBP in this KIT.Studies of agencies that have tried to replicateevidence-based practices have found that agenciesthat did not achieve positive outcomes failed toimplement all of the components of the evidencebased model (Becker et al., 2001; Bond & Salyers,2004). As a mental health authority, you can ensurethat the system has incentives to implement theevidence-based model as outlined in the FPEFidelity Scale (see Monitor fidelity and outcomesbelow). Attention to aligning these incentives in apositive way (such as attaching financial incentivesto achieving improved outcomes) is vital tosuccessfully implementing FPE programs.Advisory groups should continue to meet wellafter you have established your FPE program.We suggest that they meet about once a month forthe first year, once every 2 months for the secondyear, and quarterly for the third year. In the secondand third years, advisory groups may help FPEprograms sustain high fidelity by assisting withfidelity evaluations and outcomes monitoring ortranslating evaluation data into steps for continuousquality improvement. For more information aboutthe role of advisory groups, see Getting Startedwith EBPs in this KIT.States have the authority to adopt regulations thatgovern services to consumers. These regulations setstandards for the quality and adequacy of programs,including criteria that govern these areas:n Admission and discharge;n Staffing;Planning your FamilyPsychoeducation initiativen Service components;With a vision firmly in place, the process ofunfolding FPE programs across the service systemcan begin. Carefully planning this process willhelp ensure a successful outcome. ImplementingFPE programs first in pilot or demonstrationsites may be useful. Working with pilot sites canhelp you manage problems as they arise andalso give constituents the opportunity to see thatthe evidence-based model works. Multiple pilotsites are preferable to just one. When only onesite is used, idiosyncratic things can happen thatmisrepresent the model. In contrast, when mentalhealth authorities do a system-wide rollout, it isdifficult to adequately train all FPE program staff.In that case, system problems that may have beenresolved easily on a smaller scale with a few FPEprograms can cause havoc.n Consumer medical records;Tips for Mental Health Authoritiesn Program organization and communication;n Consumer rights; andn Supervision and program evaluation.Support FPE implementation by explicitly referringto the evidence-based model in licensing standardsand other program review documents (for example,grant applications, contracts, and requests forproposals). Review current administrative rules andregulations to identify any barriers to implementingprograms. Work closely with agency administratorsto ensure that state-level policies support highfidelity practice.12Building Your Program

Definition of FPE ServicesThe following language has been used to reimburse FPE services in Maine.There may be three or more joiningsessions, as early in the course of anepisode or illness as possible.Covered services include FamilyPsychoeducation provided in multifamilygroups and in single-family sessions.Covered services include FamilyPsychoeducation as defined underprogram elements, provided to relatedand non-related care-takers, as well as tothe eligible person. Covered services maybe provided to the participating peoplewith or without the eligible person beingpresent, if all other program requirementsand elements are being provided.Educational workshops involveidentified family members and, atthe determination of the practitionersleading the workshop, eligibleMedicaid recipients. These workshopsoffer extensive information aboutthe biological, psychological, andsocial aspects of mental illnesses; thenature, effects, and side effects ofpsychiatric treatments; what familiescan do to help recovery and preventrelapse; and guidelines for managingmental illnesses.Program elements of the covered servicesinclude joining sessions, usually involvingeligible Medicaid recipients and theirfamily member, who may meet separatelyor together, depending on clinicalcondition and other considerations to bedetermined by the eligible provider. Thesesessions focus on exploring the following:Ongoing Family Psychoeducationsessions occur biweekly in a multifamilyor single-family format, usually withthe eligible Medicaid recipient present.These sessions follow an empiricallytested format and focus on solvingproblems that interfere with treatment,illness and symptom management, andcoping skills. Case management mayalso be provided during these sessions.n Precipitants of current and/or pastacute episodes of illness;n P rodromal signs and symptoms;n C oping strategies and strengths;n F amily and social supports;n G rief and mourning in relation to theillness; andn T reatment goals and planning.Building Your Program13Tips for Mental Health Authorities

Address financial issuesWe encourage you to support agency administratorsin their efforts to develop a training structurefor implementing FPE. The training planshould include basic training for key communitystakeholders including the following:Each state is different. Typically, FPE programsare funded by a combination of state mentalhealth dollars, Medicaid, and private insurance.Funding approaches that have been used in somestates include the following:n Consumers;n Families;n Reallocating some psychosocial or psychotherapyn Mental health authority representatives; andservices for FPE services;n Staff from key community organizations.n Adopting a case-rate approach where the agencyis reimbursed monthly for each consumer tocover bundled direct and indirect costs; orThe training plan should also include basic trainingfor staff at all levels within participating agenciesand intensive training for FPE practitioners (staffwho are designated to provide FPE services).n Seeking Medicaid reimbursement.In some states, Medicaid authorities supportfunding for FPE because emergency room visitsand hospital admission

Family Psychoeducation (FPE) is an approach for partnering with consumers . and families to treat serious mental illnesses. FPE practitioners develop a working alliance with consumers and families. The term . psychoeducation . can be misleading. While FPE includes many working elements, it is not