Role of family in delivery of effective mental2


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  • No community mental health workers yet. Even the policy is a little hazy as to how the community based care is going to be provided. A strong community support system is necessary if the family is expected to provide major component of care. In our country where SSOs and other similar officers are minimally productive and expecting community services tyi pick is unrealistic. While working towards that we should not forget this valuable resource that is already there. And attempt to harness it.
  • High service use means poor disease control and low quality of life. A lack of awareness of mental illness is common among patients with schizophrenia who are nonadherent to antipsychotics. Such nonadherence tends to be especially disruptive and unresponsive to simple commonly used psychological interventions. USA 2006
  • In spite of the above information the family is underused. The overall family is underused SPECIALLY IN Sri Lanka. The staffs poor opinion of family is a theme that was seen repeatedly many studies.
  • Because they thought that involving the family was not a very useful way
  • The last one is the one on we need to work and reverse if possible. This can be done by making them partners in the process and giving control and hope.
  • This does not happen for many reasons some possible ones are these. The first has been high lighted by clients, families in many different studies.
  • In the last decade four major controlled studies have shown that relapse in schizophrenia can be improved if families receive; detailed assessments of individual need, health education about schizophrenia, and family stress management programmes, often defined as "psychosocial intervention “ are found to be useful. The lack of collaboration with health professionals increased carers' level of distress and left them feeling frustrated and resentful. Wynaden 2005
  • Considering the above we thought of addressing this issue. So this attempt made.
  • The first step would be to support. Help them to ventilate feelings freely.these are skills that professionals have.
  • We se the family and community as the essential structures that hold, help the patient in the recovery process. To maximize their involvement we need to invest in families. We see our role as working with all the layers and supporting the existing support structures to the maximum. Involvement with community is marginal yet. We need to develop strategies to do that in the future. Diagnosis and medication only become useful if the support system is in place. Other wise we only treat the episode and not the disease.
  • This shows the general model in the mental health unit earlier. We changed it and this is reflected in all aspects of care. I will come to that later.
  • Often the disease process draw the family away from the patient. This is specially seen in the serious mental disorders. Stigma, violence, delusions, the space, guilt all contribute to this process. We try and strengthen this important link using different strategies.
  • Arranged in the order of importance.
  • Arranged in the order of importance.
  • Ignoring or disregarding the family is something that is learnt during training. The natural state of affairs is the opposite. The families play an important role in our life here in Sri Lanka. This is something that they understand easily. They were able to shed that was learnt during the training and become more family oriented in their approach. Decisions to admit, going on leave, and discharge are taken in collaboration with client and family. Very rarely patients are discharged against the relatives wish. However mostly families are not unhappy to take patients back home. This may be due to they being with the patient and seeing them recover, they are sent home on leave to test, the continuing support through the hot line, Community follow up that is available to them. Very rarely clients are seen alone. Relatives are given a seat and listened to without neglecting the client. Family meetings are held for patients who are readmitted to the unit to clarify role of individuals, provide information and support to strengthen their role.
  • Arranged in the order of importance.
  • Arranged in the order of importance.
  • The study provides evidence that mutual support groups can be an effective family intervention for Chinese persons with mental illness in terms of improving patients' functioning and hospitalization without increasing their use of mental health services. HongKong 2004
  • The risk of violence faced by the family in high risk patients The incidence of depression and other common mental health problems common in carers Though coping skills generally improved might stress these to the limit
  • Ninety-five percent of the providers interpreted confidentiality policies conservatively, believing that they could not share confidential information without the consent of the client Confidentiality policies may be posing a barrier to collaboration between providers, consumers, and family members, which has been recommended by various experts for the treatment of mental illness. 2003 US this has not happened in Sri Lanka yet. However there is a danger that policies might be developed in this regard in the future. Care must be taken to draft with consideration.
  • The families of the mentally ill were compared with normative families on the variables of family stressors, family coping, and family health. The results indicate that although the families of the mentally ill have significantly more stressors than normative families, they have clear strengths relative to family coping and the family health subconcepts of adaptability and conflict management. 1996 USA
  • Role of family in delivery of effective mental2

    1. 1. Role of Family in Delivery of Effective Mental Health Services M. Ganesan Batticaloa
    2. 2. Only serious mental illnesses after contact with services considered for this presentation
    3. 3. Ways to reduce load of high service users • Community mental health services • Existing informal support system Families often serve as an extension of the mental health system, providing important functions such as assessment, monitoring, crisis management. Saunders 1997
    4. 4. 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
    5. 5. 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
    6. 6. Current state of Affairs Despite 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
    7. 7. 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
    8. 8. 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
    9. 9. 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
    10. 10. 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
    11. 11. 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
    12. 12. 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
    13. 13. 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
    14. 14. The Model Community Extended family Immediate family Client Mental health services
    15. 15. 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
    16. 16. The Model Client Family Providers
    17. 17. 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)
    18. 18. 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
    19. 19. 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
    20. 20. 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
    21. 21. 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
    22. 22. 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?
    23. 23. 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
    24. 24. 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
    25. 25. 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
    26. 26. Some figures in 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
    27. 27. 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
    28. 28. Visiting Hours • Relatives allowed at all times – no visiting hour restrictions • Any number encouraged • Often share a meal
    29. 29. Other possible strategies • Family units • Community support groups • Family group training sessions • Rapid response teams • Support from PHC team • Respite care
    30. 30. 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
    31. 31. 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?
    32. 32. Why Family • Always with patient • Understand the patient better • Cheaper • Less stigmatizing • Committed/ has interest at heart
    33. 33. 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
    34. 34. Thank You