Michelle D. Sherman, Ph.D.

Transcription

1 Michelle D. Sherman, Ph.D. Director, OKC VAMC Family Mental Health Program Clinical Professor, University of Oklahoma Health Sciences Center, Core Investigator, South Central MIRECC

2 Overview 1. Rationale for creation of REACH (Reaching out to Educate and Assist Caring, Healthy Families) 2. Selection of the evidence-based model to tailor for PTSD and the VA 3. The REACH intervention & guiding principles 4. Participation, outcome, and satisfaction data

3 75% of married/cohabiting OEF/OIF/OND veterans referred for mental health evaluation at the VA had some family problem in the past week 86% of veterans in a VA PTSD outpatient program reported that PTSD was a source of family stress Sayers, 2009; Batten et al., 2009

4 What About the Partners? Partners of veterans with PTSD experience: High levels of caregiver burden High levels of overall psychiatric stress Compared to partners of veterans without PTSD, they report: Lower relationship satisfaction Poorer psychological adjustment Jordan et al., 1992; Calhoun et al., 2002; Beckham et al., 1996; Manguno-Mire et al., 2004

5 What About Family Involvement? 79% of veterans expressed interest in greater family involvement in an outpatient VA PTSD program Over ¾ of live-in female partners of veterans with PTSD rated getting couples/family therapy as very important in coping with PTSD in the family Conjoint treatment has been found to be effective with other disorders (depression, substance abuse, schizophrenia) Sherman et al., 2004; Batten et al, 2009; Beach et al., 1996; Jacobson et al., 1991; O Farrell et al., 2006; Pfammatter et al., 2006

6 ISTSS guidelines (Glynn, Drebing & Penk, 2009) recommend family education/support for PTSD treatment VHA Handbook (July 1, 2011): Opportunities for family consultation and family education (e.g., SAFE Program) or family psychoeducation (FPE) must be available for all veterans with serious mental illness

7 Recommends: the DOD & VA should institute programs of research to evaluate the efficacy, effectiveness, and implementation of all their PTSD screening, treatment, and rehabilitation services Recommends that couple and family therapy need to be rigorously evaluated for efficacy, effectiveness, and cost (pages 13-14).

8 Manualized interventions originally created for schizophrenia Goal: To equip families with the skills known to reduce relapse and improve quality of life Emphasis on: Careful assessment Education about the illness Problem-solving

9 Meta analyses have concluded that benefits of FPE for schizophrenia (when added to standard pharmacotherapy) include: Reduced risk of relapse Remission of residual psychotic symptoms Enhanced social & family functioning Financial savings ** Findings are robust across cultures & sustainable across time. ** FPE is increasingly being used with a variety of other mental illnesses

10 Further, families who get FPE report: Less burden Decreased burnout & distress Fewer psychosomatic difficulties Greater effectiveness in helping their loved one

11 REACH = Reaching out to Educate and Assist Caring, Healthy Families Chose McFarlane s Multifamily Group Model due to its strong evidence base & group format Modified for use in the VA system and for use with PTSD Funded in 2005 as part of VACO Mental Health Enhancement funding

12 2 focus groups (veterans with SMI/PTSD and family members) Goal = To better understand the needs and treatment preferences of local families Findings: Veterans want family involvement to help family better understand their illness Family members want to be involved in veteran s care Want evening services Inviting family members should occur though the veteran

13 Instillation of hope Acknowledgment of PTSD as a real phenomenon, yet empowering to make positive changes Focus on making small 1mm changes Treat veterans/support persons as guests in your living room

14 Emphasis on a long-haul mentality (marathon rather than a sprint ) Challenge by choice REACH is not solely about/for the veterans Honor family strengths

15 REACH PTSD Cohort Eligibility Criteria: 1) Primary diagnosis of PTSD 2) Residence within 90 miles of the VAMC 3) Adult family member/friend willing to participate Exclusion criteria: 1) Primary substance abuse disorder 2) Imminent danger to self or others

16 Elicit referrals from staff from numerous programs: On-call REACH psychologist meets with interested veteran immediately after his/her scheduled psychiatric appointment Motivational interviewing Emphasis on helping them achieve goals by involvement of family member Describe structure of program

17 Phase One: Four weekly 45-minute single family sessions Goals: Build rapport Assess precipitants & prodromal signs Begin to enhance coping strategies Define goals for this family Assess social history, family resources, support network Identify family strengths

18 Goals: o o o Psychoeducation about PTSD and its impact on family Teach communication, problem-solving and coping skills Relationship enhancement 4-8 families/cohort

19 Structure: Check-in and follow-up on homework 20 minute didactic (interactive) presentation Split into break-out groups (veterans and support persons separately) for minute presentation/discussion Reconvene for entire class demonstration and insession practice Assign homework

20 1. PTSD diagnosis, treatment, and effects on relationships 2. Managing anger/conflict effectively and promoting wellness 3. Communication skills 4. Creating a low stress environment 5. Depression and its impact on the family 6. Problem solving / Phase II Graduation

21 Six monthly 90-minute multi-family groups Practice with problem-solving process Review and rehearse skills from Phase II Support maintenance of gains

22 Entire curriculum and student workbook are available for free download: Special thanks to the SCMIRECC for funding the creation of the manual.

23 In addition to working with veterans with PTSD and their families, we provide REACH to two other diagnostic groups: 1. Affective Disorders (AD) including depressive disorders and bipolar disorder 2. Schizophrenia spectrum disorders (SSD) Stay tuned!

24 Have done engage interviews with 3,380 veterans to inform them about REACH 791 Veterans have participated in REACH 40 Nine-month PTSD cohorts 40 Nine-month Mood disorders cohorts 8 Nine-month Schizophrenia cohorts

25 ~95% of participants in clinical REACH Program consent to voluntary REACH evaluation Veterans and family members complete a battery of self-report measures at 4 times Baseline End of Phase 1 End of Phase 2 End of Phase 3

26 Veterans (n=100) Family (n=96) Age (mean (IQR)) 55.8 (57-62) 52.7 (46-61) % Male 99% 4% % Married 87% 93% Race/ethnicity White 87% 82% Hispanic 4% 1% Black 8% 7% Native American 1% 8% Fischer et al., (2013)

27 Veterans (n=100) Family (n=96) Education Less than HS 5% 10% HS/GED 33% 38% Some college 35% 36% College graduate+ 18% 15% No information 9% 1% Relationship to veteran Spouse % Parent -.- 3% Sibling -.- 4% Child -.- 2%

28 Veterans (n=100) Family (n=96) Measure Estimate Sign. Estimate Sign. PTSD Facts 6.29 < <0.01 PTSD Understanding 1.03 < <0.01 PTSD Coping 0.52 < <0.01 Empowerment < Rogers (veterans)/koren (family) score sums * Repeated measures analysis (SAS Genmod)

29 Veterans (n=100) Family (n=96) Measure Estimate Sign. Estimate Sign. Social Support <0.01 Problem Solving NS 0.22 <0.01 Relationship Satisfaction < <0.01 Symptoms (Brief Symptom Index) Global Sx Index < <0.01 Depression < Multidimensional Scale of Perceived Social Support (avg.) 2 McCubbin Family Problem Solving Communication Scale (avg.) 3 Dyadic Adjustment Scale-7; distressed relationships only * Repeated measures analysis (SAS Genmod)

30 For family, increases in perceived ability to cope and empowerment mediate * improvements in social support and problem solving; increases in perceived coping are associated with improvements in BSI global symptom severity and depression scores * Multivariable fixed effects models (SAS GLM; all mediator p s<0.05)

31 96% of participants said they were either very satisfied or mostly satisfied with the REACH Project 98% of participants were very satisfied or mostly satisfied with their doctors 96% of participants rated the quality of REACH as excellent or good 97% said REACH helped a great deal or helped somewhat 100% said they would recommend REACH to someone with a similar need

32 Compared 12 months before starting REACH to 12 months after finishing REACH On average, veterans used fewer VA outpatient mental health services in the 12 months AFTER REACH than they had in the 12 months before starting (1.71 encounters/month versus 2.89 encounters per month; t=2.61, df=99, p=0.002)

33 Durham and the Bronx VA have done MFGs for PTSD and TBI, incorporating some of REACH (Perlick et al., 2013; Straits-Troster et al., 2013) Atlanta VA and Reno Vet Center are providing REACH for PTSD Togas, Maine VA is applying for funding to implement and evaluate REACH Honolulu VA / National Center for PTSD are using the REACH curriculum for their research project with OEF/OEF PTSD couples Others in consideration

34 REACH-PTSD is a feasible, well-received, effective family intervention for trauma Additional tool for clinicians (before, after or during EVTs for PTSD) Introduces norm of family involvement Assessing need for modifications to tailor REACH to appeal specifically to OEF/OIF-era veterans Assessing effectiveness with mood disorders

35 Fischer, E.P., Sherman, M.D., Owen, R., & Han, X. (2013). Outcomes of participation in the REACH multifamily group program for Veterans with PTSD and their families. In press. Sherman, M.D., Perlick, D., & Straits-Troster, K. (2013). Adapting the multifamily group model for treating Veterans with PTSD. Psychological Services. Sherman, M.D., Fischer, E.P., Bowling, U.B., Dixon, L.B., Ridener, L., & Harrison, D. (2009). A new engagement strategy in a VA-based family psychoeducation program. Psychiatric Services, 60, Sherman, M.D., Fischer, E.F. Sorocco, K., & McFarlane, W. (2009). Adapting the multifamily group model to the Veterans Affairs system: The REACH program. Professional Psychology: Research and Practice, 40(6),

36 Thank you! Michelle D. Sherman, Ph.D