Role of Family in Delivery of Effective Mental Health

Services

M. GanesanBatticaloa

Only serious mental illnesses after contact with services considered for this presentation

Ways to reduce load of high service users

• Community mental health services

• Existing informal support systemFamilies often serve as an extension of the mental health system, providing important functions such as assessment, monitoring, crisis management.

Saunders 1997

High service users other than disease factors

• Poor family support

• Poor insight

• Migrant workers

• Poverty

• Difficult access to services

• Poor Knowledge and attitude of family

Family under used

Consumers' reports revealed a strong reliance on sources of support outside the mental health system (e.g., family and friends) for many community support service needs, interpersonal needs, and crisis-related needs. Case managers thought otherwise.Crane Ross et al 2000

Current state of AffairsDespite the well-documented efficacy

• clinicians have rarely included these methods in their professional repertoires

• must include family psycho education in the spectrum of services provided by a clinic, mental health center, community support program, hospital.

• intensive training over several months led to implementation of new family programs. Amenson, Liberman Psych services 2001

Four junctures in the caregiver-patient relationship

• Before diagnosis, respondents experience emotional anomie.

• Diagnosis provides a medical frame that provokes feelings of hope, compassion, and sympathy.

• Realization that mental illness may be a permanent condition ushers in the more negative emotions of anger and resentment.

• Caregivers' eventual recognition that they cannot control their family member's illness allows them to decrease involvement without guilt.Karp 2000

Current State

• Families marginalized by service providers

• Families often do not understand patients behaviour

• Patients feel neglected by families

• Families have no easy access to service providers

Current Pitfalls marginalized by service providers

• Not listening to family concerns

• Not explaining to family

• Often blaming relatives for the illness and relapse

• Increased frustration and resentment

Wynaden 2005

Current Pitfalls often do not understand patients behaviour

• Alternative belief systems

• Feel hurt by paranoid delusions

• Anger due to violence

• Space for ventilation not provided (pushed into a carers role)

• Proper explanations, skills not given

Current Pitfalls Patients feel neglected by families

• Difficulty in visiting patient – distance, staff attitude – create a sense of unwanted

• Last contact between patient and family unpleasant

• Often brought against patients wish

An attempt

To involve the family in a systematic and conscious manner from the initial contact onwards to maximize their involvement in the planning and delivery of care

To Utilize Families

• Family has to be supported

• Attitude of family to illness and person should be positive

• Must be valued as important partner by team

• Should actively participate in care throughout

The Model

Community

Extended family

Immediate family

Client

Mental health services

The Model

Providers

Clients

Family

Providers

Family

Mental health professionals do not often collaborate with families when providing treatment to the mentally ill, even though research shows better patient outcomes with family involvement.

Kaas 2003

Client

The Model

Client Family

Providers

Problems in this strategy

• Patients with no family

• Family given up hope and not interested

• Family not having the skills

• Elderly parents

• Not wanting to get involved due to stigma (extended family)

Some attempts to involve families in Batticaloa

• Bystander

• Staff aware of role of family in care

• Telephone,hotline

• Environment

• Visiting hour restrictions- relaxed

• Family meetings

• Active involvement in rehab, PSW visit

Family Member as Bystander

• Very few families find it difficult

• Cross gender bystander allowed

• Paid (non relative) bystanders discouraged

• More than one bystander allowed

• Children allowed– Food problem

Family Member as Bystander - Benefits

• Less abuse

• More aware of disease and medication

• Sees other patients recovering and going

• Sees the improvement in patient

• Participates in the ward culture

• Easier to know strengths and weaknesses of the family

Some attempts to involve families in Batticaloa

• Bystander

• Staff aware of role of family in care

• Telephone,hotline

• Environment

• Visiting hour restrictions- relaxed

• Family meetings

• Active involvement in rehab, PSW visit

Staff Attitude to Family

• This changed quickly ( positively)

• Naturally the families play an important role in our lives – this may have made it easier for the staff to change attitude easily

• Nurses are still taught not to tell name to patient?

Some attempts to involve families in Batticaloa

• Bystander

• Staff aware of role of family in care

• Telephone,hotline

• Environment

• Visiting hour restrictions- relaxed

• Family meetings

• Active involvement in rehab, PSW visit

Telephone

• Have for 3 years

• Patients, bystander can call home - 4/ day

• Can receive calls from home - 3/ day

• Pay the cost of call

Hot line

• Patient/ family call for general advice or when there is a crisis – 4/ day

Rehab

Psycho educational multiple-family group intervention was effective in managing negative symptoms over a 12-month period. – fortnightly meetings at rehab center

negative symptoms are associated with relapse, poor social and occupational functioning, cognitive impairment, and lower subjective quality of life.Dyck et al 2000

Some figuresin one month……

• No of admissions 47 (M -20, F -27)

• New patients 29 Known patients 18

38% readmission

• mean stay in ward 7 days

• Longest stay 26 days ( including days spent at home on leave)

• Referred for community follow up 20

Some attempts to involve families in Batticaloa

• Bystander

• Staff aware of role of family in care

• Telephone,hotline

• Environment

• Visiting hour restrictions- relaxed

• Family meetings

• Active involvement in rehab, PSW visit

Visiting Hours

• Relatives allowed at all times – no visiting hour restrictions

• Any number encouraged

• Often share a meal

Other possible strategies

• Family units

• Community support groups

• Family group training sessions

• Rapid response teams

• Support from PHC team

• Respite care

Harm in involving the family

• Worsen relationship between family and patient

• Feel burdened, Difficult in coping with extra responsibility

• Feeling responsible and guilty for a relapse

• Over enthusiastic effort leading to relapse

• Patients freedom may be undermined

Ethical issues

• Should we involve the family?

• Confidentiality. Carers have identified that patient confidentiality was one reason why health professionals were unwilling to collaborate with them.Wynaden 2005

• Coercion?

Why Family

• Always with patient

• Understand the patient better

• Cheaper

• Less stigmatizing

• Committed/ has interest at heart

Benefits of this strategy

• Dignity of patient is protected and maybe enhanced

• Cheaper?• Tuned to the patient needs and skilled• Knows the weaknesses and strengths of the

patient• Knows the patients pre morbid state well• Long term commitment• Family feels confident in managing the patient

Thank You