Patients with severe mental disorders get better treatment with family involvement

A new study contributes to new knowledge about what prevents and promotes family involvement in treatment of patients with severe mental disorders.

"We know what the best treatment for severe mental disorders is. Family involvement in treatment of patients with severe mental illnesses is recommended in guidelines throughout the western world. Regardless, it is not always done, with significantly negative consequences for patients, relatives, the health care system and the society," Kristiane Myckland Hansson says.

She is a Ph.D. research fellow at the Centre for Medical Ethics at the University of Oslo.

"Family involvement in psychiatry is often the result of work done by individuals with an interest in this. Sometimes the families are included, other times they are not. Personal interest can not determine what kind of treatment the patients are offered," she says.

Need to know what prevents family involvement

Myckland Hansson and colleagues have studied factors that prevent and promote family involvement. Systematic family involvement is central to be able to provide proper treatment. One of the study's most important contributions is to help narrow down the gap between what we know work and what actually happens in the clinics.

"To achieve better family involvement, we need to know what does not work. A lot of research has focused on this previously, but our main focus has been what makes it work," says Myckland Hansson.

The study is part of the research project "Family involvement during severe mental health problems." The main aim of the project is to improve family involvement, for the patient and the health care system, and thus improve the psychosocial health of the patients and their relatives, as well as the quality of the services.

Less chance of relapse with family involvement

Research shows that family involvement has a positive impact on patients and their families. For the patients, it leads to less chance of relapse, better medication, fewer hospitalizations, and less strain on the health care system. The families can provide better care and support for the patients.

"In the case of serious mental illnesses, society, the health care system, patients, and their relatives are affected. This is why we should do what we can to offer patients the best possible treatment," Myckland Hansson says.

In the past it was common to blame the family for the patient's illness, she explains. Fortunately, we know better today. The family is crucial for the patient's recovery process.

"We depend on the relatives. They have to contribute by help and care outside the health services. Otherwise, the health care system would not be sustainable. Relatives can be a great resource for clinicians and the health services and know how the patients function in different situations and contexts."

It can be a huge strain on the families to have a family member who is struggling. It is important to start working together with the families early in the treatment process, in order to create trust and a good dialogue between everyone involved. This is how to prevent conflicts, optimize the patient's resources and ensure that relatives receive support.

"Relatives of people with mental disorders have generally been given little attention, and have sometimes been neglected and rejected by the health services. At the same time, with fewer bed posts and shorter follow-up time in psychiatry, it is necessary that they contribute. Why is family involvement so lacking when they are so important?" Myckland Hansson asks.

Factors that prevent and promote family involvement

The study revealed several factors at different levels that prevented family involvement in the treatment of patients with severe mental disorders.

Central factors were lack of competence and experience with family involvement among the staff in the treatment units, lack of awareness of measures that can be made to involve families, negative attitudes towards family involvement, limited access to training and guidance, lack of priorities, routines and practices of family involvement, lack of managerial support and lack of resources in the units.

"Proper family involvement must be built over time and on several levels at once. It does not help with dedicated clinicians if the organization or treatment unit they work in does not facilitate systematic family involvement. This makes it difficult to achieve practical solutions for family involvement," Myckland Hansson says.

Factors that promote family involvement at an organizational level in the treatment units were a holistic approach at the department, clear roles and responsibilities for promoting involvement, standardization of routines, and simple tools for and knowledge of dealing with central factors that prevents involvement. This could, for instance, be handling confidentiality and situations where the patient refused to involve their families.

For the clinicians in the units, training and guidance in family involvement was important. This resulted in higher competence and increased awareness of and better attitudes towards family involvement in the treatment units.

Researchers have introduced measurements to promote better family involvement

In the study, family involvement was implemented based on national guidelines and guidelines for family involvement. The research group introduced measures to create increased involvement and support in the entire treatment unit. The key was to provide training to all staff on how to include the families, and to help the departments establish viable routines of offering a basic level of family involvement for all patients.

Health care personnel received training and guidance in psychoeducational family involvement (PEF) from TIPS Sør-East. Here the clinicians teach the families to work together, develop communication skills, problem solving and to gain insight into symptoms and stress factors.

"The goal was for all employees to have the same competence, a shared culture, goals and practice for family involvement. We achieved this through standardization of routines at organizational level, including of managers and by working with each individual clinician," Myckland Hansson says.

The research group followed the treatment units for 18 months as they worked on introducing the measures. The units appointed a family involvement coordinator and an improvement team, who were responsible for working on improving the involvement.

Myckland Hansson explains it was exciting seeing changes at both group and individual levels.

"We saw that therapists often focused on lack of time and resources. Some had never worked with family involvement and did not know what that meant. Gaining personal experience with family involvement that works, after receiving training, was an important promotional factor."

Family involvement makes a difference for families and patients

"Systematic family involvement is a complex intervention, the implementation requires effort, expertise and resources, but we see that the health services are very successful when they do this. The involvement makes a difference for patients and relatives. It is one of the most effective treatments we have for psychosis," Myckland Hansson says.

She believes that PEF and more basic family involvement, in the form of conversations with relatives and patients separately and together, is something all units that treat patients with severe mental disorders can and should achieve.

"Systematic conversations about family involvement should be offered as a default approach, and it should start as early as possible in the treatment process," she says.

The research was published in BMC Health Services Research.