Pyramid of Family Care Revisited: Family Needs & Our Resources

Yasaman Mottaghipour, Ph.D

Overview

• Introduction • Pyramid of Family Care• Pyramid Journey• Capacity Building • Training • Supervision

Literature

• Family intervention efficacy in: – reducing relapse rate– decreasing stress and burden

• Family intervention/diagnosis• Service delivery level/effectiveness• Collaborate with families

(not pathologise)

Barriers to Family Work

• Skills and training• Confidentiality• Resources • Attitudes - family work “highly specialized”

Family Needs

• Information/education• Coping skills • Crisis support• Communication• Rarely family therapy

Pyramid of Family Care:A framework for family involvement with

adult mental health services*

*Mottaghipour Y. & Bickerton A.

The Pyramid of Family Care:Concept

• Food Pyramid

• Maslow’s Pyramid

Maslow’s Pyramid

Physiological Needs

Safety Needs

Belonging Needs

Esteem Needs

Self- Actualisation

Pyramid of Family Care

Minimum standard of care

Pyramid of Family Care:Overview

• User friendly template for everyday practice• Basic to specialised• Clinical and training tool• Minimal standard of care• Collaboration

Pyramid of Family Care:Confidentiality dilemma

• Consent important

• Confidential and non-confidential information

Pyramid of Family Care

Minimum standard of care

Pyramid of Family Care

I.Connection & Assessment

Minimum standard of care

Pyramid of Family Care:I. Connection and Assessment

• Introductions and explanation of the family service partnerships

• Documentation of the contact details of key family members

• Assessment of the urgent and basic needs of family• Establishment of a system of safety• Orientation to the Mental Health service• Development of a plan and involvement of other

agencies (as needed)

Pyramid of Family Care

I. Connection & Assessment

II General Education

Minimum standard of care

Pyramid of Family Care:II. General Education

• Assessment of needs• Education:

– Mental health services– Illness/treatment– Mental Health Act– Community resources & NGO

• Referral and liaison (as needed)

Pyramid of Family Care

I. Connection & Assessment

II. General Education

III. Psycho-education

Minimum standard of care

Pyramid of Family Care:III. Psycho-education

• Assessment of needs• Psycho-education:

– Single family education session– Family education group

• Referral and liaison (as needed)

Pyramid of Family Care

I. Connection & Assessment

II. General Education

III. Psycho-education

Minimum standard of care

IV. Consultation

Pyramid of Family Care:IV. Consultation

• Assessment of needs• Continue contact and support• Consultation (as needed)• Referral and liaison (as needed)

Pyramid of Family Care

I. Connection & Assessment

II. General Education

III. Psycho-education

V. Family Therapy

Minimum standard of care

IV. Consultation

Pyramid of Family Care:V. Family therapy

• Assessment of needs• Family therapy• Ongoing liaison between professionals

Pyramid of Family Care:Moving up the Pyramid

• Family related factors:– High distress– Problems in other family members– Pre-existing risk factors - eg. family violence

• Illness related factors:– Type– Chronicity– Disability

Uses of the Pyramid of Family Care

• Clinical tool• Quality assurance• Standardization• Training tool• Service development• Research

Pyramid of Family Care:Conclusion

• Framework for involving families in everyday practice

• Higher level interventions are built upon family- service partnerships

• Empowering clinicians to work with families

Pyramid of Family Care Premises

• If all family members have their basic needs met, then only a small proportion will need specialized services

• It is within the scope and competence of generalist mental health service providers to engage, assess and address the basic needs of most family caregivers

Pyramid of Family Care

I. Connection & Assessment

II. General Education

III. Psycho-education

V. Family Therapy

IV. Consultation

Minimum level of care

Pyramid of Family Care Journey

Connecting with CarersIs Everybody’s Business

• Training resource• Handbook and DVD• Capacity building• Pyramid of Family Care

Bickerton A. et al. Working with Families Program, Sutherland Division of Mental Health, South Eastern Sydney Illawarra Area Health Service, NSW Health 2007.

Questions to Consider

• Rate your service. What parts get higher or lower rating?

• How families/carers will rate your service?• Children• Sibling• System of safety

Pyramid of Family Care/Educational Package

• Education package based on level two and three of the Pyramid

• 14 modules to use for family education– Clinical guide– Presentation– Fact sheet– Video clip

Hassack K. Connecting with Carers through Education: a guide for mental health service providers. South Eastern Sydney Illawara, NSW 2010.

Hossack k. et al. Connecting with Carers through Education: a guide for mental health service providers, South Eastern Sydney Illawarra Health Service, NSW Health 2010.

Pyramid of Family Care/Cultural

• Connecting with Culturally and Linguistically Diverse (CALD) carers

• Linguistic• Cultural • Acculturation• Stigma

Woodland Lisa, et al. Connecting with Carers from Culturally and Linguistically Diverse Backgrounds, Multicultural Health and Mental Health Services, South Eastern Sydney Local Health District, NSW Health 2012.

Pyramid of Family Care/Cultural

Level One: Connection and Assessment

• Interpreter / Confidentiality• Bilingual• Cultural background• Level of acculturation • Intergeneration conflict

Level Two:General Education

• Myths about mental illness• Stigma : experience and judgment of community• Experience of mental health services in country of

origin• Preferred language and English• Multicultural community supports• Education to significant people in the community

Questions to Consider

• What techniques and resources do you have in your service for connecting with CALD carers?

• What barriers do you encounter in your service?

Working with “CALD” Carers

• Language• Cultural • Higher level of stigma?• Immigration issues• Lower level of mental health literacy• Resources• More similarities

Project Air Strategy for Personality Disorders*

• Project for personality disorder• Improve capacity of mainstream health services• Referral pathways between generic and specialist

treatment• Use of Pyramid of care • Training

Grenyer BFS & Fanaian M (2015) Final report on the treatment of personality disorders research project (2010-2013) Wollongong: University of Wollongong, Illawarra Health and Medical Research Institute

* Grenyer BFS & Fanaian M (2015). Final report on the treatment of personality disorders research project (2010-2013) Wollongong: University of Wollongong, Illawarra Health and Medical Research Institute.

Pyramid of Family Care:Similar Settings

• Responding to the need of children and parents in families experiencing drug and alcohol problems

• The Supervisor’s guide: Integrating Family Inclusive Practice into Clinical Supervision for the Addiction Workforce

• National Guidelines for a Comprehensive System to Support Family Caregivers of Adult with Mental Health Problems and Illnesses

Pyramid of Family Care Guidelines

• 70% women• 60% employed• 20% care for another person as well• 47% over 5 years of caregiving• Take care of their grandchildren• 10% of clients refused consent, but half of family

caregivers were contacted.

Summary: Pyramid of Family Care Journey

• Educational / Training• Linguistic and Cultural considerations• Manual for families• Guidelines• Applying to Other diagnostic categories

Developing Family Friendly Services

• Pyramid of family care• Cost effective• Sustainable family friendly services• Capacity building

• How family friendly your service is?

Capacity Building

• Leadership• Organizational structures• Workforce development• Strategic resource allocation• Partnerships

Capacity Building

• Leadership : Support for family friendly initiatives at all levels

• Organizational structures/organizational support– Committees– Policy and procedures– Core clinical group

Capacity Building• Workforce development

– Training for staff– Supervision and consultation

• Strategic resource development– Factsheets and packages– Family room

• Partnerships: Working with Non Government Organizations

Capacity Building

• Initial linking and engagement of families

• Knowledge and skills

• Support for families

Training and Supervision

Carers’ Experience

• Burdensome responsibility• Roller coaster and unpredictable experience• Feeling responsible for their illness• Coming to terms with the change• Becoming closer• Maintaining hope

McCann TV, et al. First-Time Primary Caregivers’ Experience of Caring for Adult with Frist-Episode Psychosis. Schizophrenia Bulletin , 37(2):381-388, 2011.

Experience of Family Psychoeducation

• Alliance• Support• Anxiety and tension• Knowledge and learning• Time• Structure• Nilsen L. et all. Patient and members experiences of a psychoeducational family

intervention after a first episode psychosis: a qualitative study. Issues Mental Health Nursing 35(1):58-68, 2014.

Pyramid of Family Care:Baseline Clinician Skills

• Counselling • Empathic listening• Skills in developing a working alliance• Knowledge of mental illness

Training:Connection and Assessment

• “CAP” – Connect , Assess and Plan*• Change of attitude• Shared language• Words to use when working with carers and

patients/clients

*Mottaghipour Y. & Bickerton A.

Outline of the “CAP” :Family Assessment Proforma

• Reason for referral

• Genogram

• Family and the illness:– Knowledge – Impact– Past treatment experiences

Outline of the “CAP” :Family Assessment Proforma

• General Family Assessment:– History– History of family violence/child at risk– Structure– Communication patterns– Life cycle changes– Family - community relationship– Family’s strengths– Stress level

Process of Family Recovery

• Denial

• Recognition

• Coping

• Advocacy

Denial

Skills Information Experience

Survival skills •Etiology•Treatment•Prognosis

•Devastation•Guilt•Shame•Blame•Anxiety•Depression

Recognition

Skills Information Experience

•Crisis response skills•Negotiating skills

•Meaning of symptoms•Resources•Medications

•Hopelessness•Limitation of services•Disillusionment•Worry•Burn-out•Mourning•anger

Coping Skills Information Experience

•Personal stress management skills•Symptom/problem behavior management skills•Collaboration skills

•Personal stress•Managing symptoms•Self-help groups

•Accepting chronicity•Letting go of dreams•Acknowledging personal limits•Trying new behavior•Focus on management

Advocacy

Skills Information Experience

•Advocacy and organizational skills•Educational skills

•Public relations•Political process•Advocacy

•Confrontation•Initiation•Assertiveness•Transformation•New awareness of personal power•Renewed capacity to feel alive and excited

Training:General Education

• Workshop– Genogram– Family of origin– Family questions/ group exercise– Resources– Role playing

Training: Psychoeducation

• Workshop– Referral– Contact– Preparation– Observers– Content– Role playing

Training: Consultation

• Direct service for families • Training for staff• Family consultation session:

– Clinician referral– Consultation team– One way mirror– Family viewing consultation team as well– Therapeutic summary letter

Family therapy

Supervision

• Parallel process/ booster session for us?

• Adherence to protocol

• Shared/common language

Supervision

Supervision, Supervision, Supervision !!

What We Gain?

• A team member• Ally• Better outcome• Satisfaction