People Recover

Treatment is effective

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Behavorial Health is Essential To Health

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The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS)."

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Quick Poll

The screen is going to change in just a second.

Please select the answer that is most true to you.

When you think of the word “FAMILY” what other words come to mind?

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Answer Below

The Role of Community and Family Supports In

Helping People Manage Their Complex

Health ConditionsIntegrating Healthcare to Promote Wellness

Anita Fisher, Director of EducationNAMI San DiegoRTP Steer Committee Member

Deborah Werner, MASenior Program ManagerAdvocates for Human Potential

WHERE THE FAMILY MEETS THE TEAMIntegrated Healthcare and the Person: Mental Illness, Substance Abuse, Trauma, and Homelessness

Families are…

• Economic units … Households• A primary way we pass on cultural traditions and teach how to

interact with other people.• The basis for child rearing.• Complex in their

definitions, roles, responsibilities, and interactions.

Other things may change us, but we start and end with families. Anthony Brandt

Family networks are often complex

step-sisters/brothers

Who does the family member

think of as “family”?

parentsgrandparents

godparents

supportive long-term friends

children

aunts/uncles

cousins

step-parentsfoster-parents

half-siblings

pets

significant others & partners

children’s fathers

spouse

siblings

What have you seen? Think of a family you have worked with which really stands out in your mind.• What was their story (before

you met them)?• What stressors did this

family experience? • What were the needs of

the family?• How were family members

resources for each other?

Mental illness, substance abuse, homelessness, trauma, and families

• Mental illness, substance abuse, and other complex issues are not experienced in a vacuum, family and friends are impacted, too.

• The same is true of the trauma of homelessness.

• Even in recovery, families feel the effects of the powerful currents that have moved them, separately and as a unit.

Substance abuseis often an inter-generational cycle

Children of parents with substance abuse disorders have a significantly higher likelihood of developing substance abuse problems themselves.

Lander, L., Howsare, J., & Byrne, M. (2013). The Impact of Substance Use Disorders on Families and Children: From Theory to Practice. Social Work in Public Health, 28(0), 194–205. http://doi.org/10.1080/19371918.2013.759005

When families become homeless, they lose…

• Their familiar place to live• Their belongings, documents,

photographs, valuables• Their routines, school,

neighborhood• Their privacy, sense of safety,

security, and control• Often, the family itself is

broken up and not able to stay together

Family separations

• Substance abuse, mental illness, or homelessness may lead to parents and children being separated.

• Some family shelters or residential treatment programs will not accept boys or men; many cannot house large families.

• Family homelessness canresult in minor children living in foster care or with extendedfamilies.

Both separation and reunification can be stressful for the family.

Children experiencing homelessness are more likely to also experience behavioral health concerns

1 in 5 preschoolers have emotional problems that require professional care.Nearly half of school-age children have problems with:

• Anxiety• Depression, or• Withdrawal

National Center on Family Homelessness, Homeless Children: America’s New Outcasts (Newton, MA, 1999)

Homelessness and trauma

Many individuals who have experienced either homelessness or substance abuse (or both) have also had other traumatic experiences, such as witnessing violence or being assaulted or abused themselves.

Homelessness itself is a traumatic experience.

Maguire, N., Greene, A., Willoughby, K. (2017) Psychological factors implicated in homelessness: an investigation into the mediating role of emotion regulation difficulties in the relationship between childhood trauma and maladaptive behaviors. Behavioral Research and Therapy

Trauma and homelessness among mothers

• Over their lifetime, 92% experienced severe physical and sexual assault.

• 25% experienced random violence.• 66% experienced severe physical

violence as children.• 43% were sexually molested

as children.

Bassuk EL, Weinreb L, Buckner J, et al. (1996). The characteristics and needs of sheltered homeless and low-income housed mothers. JAMA, 276(8): 640-646.

Trauma and children

• 83% of children 12+ years old who experience homelessness have also been exposed to violence.

• 1 in 4 witnessed violence in their own family.

Buckner J, Beardslee W, Bassuk EL. (2004). Exposure to violence and low-income children’s mental health: Directed, moderated, and mediated

relations. American Journal of Orthopsychiatry, 74(4):413-423.Photo courtesy of: Pink Sherbert Photography

Like substance abuse, domestic violence may cross generations

Children who witness violence have a greater acceptance of violence as a way to resolve conflict. ..

…unless there is healing and a chance to learn new ways to

handle stress.

Violence and the Family: Report of the APA Presidential Task Force on Violence and the Family. http://www.nnflp.org/apa/APA_task_force.htm

Using Family and Natural Supports in Integrated Care Complex health issues often have a disruptive, stressful, and challenging impact on the person seeking care, their family members and significant others.

“On Pins and Needles”

A study conducted by the National Alliance for Caregiving:

• Conducted in partnership with the National Alliance on Mental Illness and Mental Health America

• Quantitative online interviews with over 1,600 caregivers

• Findings may underestimate challenges as respondents were typically more educated and wealthier than the general public

http://www.caregiving.org/wp-content/uploads/2016/02/NAC_Mental_Illness_Study_2016_FINAL_WEB.pdf

The big picture • 8.4 million Americans care for an

adult with an emotional or mental health issue.

• Caregivers have typically provided care for 8.7 years, while caregivers of an adult care for 4 years on average (any condition).

• Most recipients (58%) are between 18-39 years; most caregivers (45%) are parents caring for an adult child, though other relationships can be impacted

• The main conditions requiring care are bipolar disorder (25%), schizophrenia (25%), depression (22%), and anxiety (11%)

Caregiving in the U.S. 2015, National Alliance for Caregiving and AARP Public Policy Institute

Who are the caregivers?

• Most caregivers were female (80%)• They usually are caring for a relative (88%) • Half are caring for an adult son or daughter

• Most are between the ages of 45 and 64 (average age is 54.3 years old)

• 65% had a college education or more advanced degree

• 46% had a household income of $75,000 or more

• 24% lived in rural areas

Caregiving in the U.S. 2015, National Alliance for Caregiving and AARP Public Policy Institute

For whom are they caring?

• Most family members being cared for are under age 40, while the median age is 46.3

• Almost half live in same household (45%) or within 20 miles (27%) as their caregiver

• 30% of the individuals also have an alcohol or substance abuse issue

• Almost half are financially dependent on family and friends

Caregiving in the U.S. 2015, National Alliance for Caregiving and AARP Public Policy Institute

Defining family and natural supports?

• Spouses, parents, and other relatives

• Old or newly formed friendships

• Community connections and resources

• Peers met in treatment or support groups

“Family is not always about blood. Sometimes it’s about who

is there to hold your hand and support you, when you need it.”

Davidswordsofwisdom.com

Engaging family and natural supports• Partnership• Collaboration• Negotiation• Dignity and respect• Information sharing• Provision of care in the

context of family and community

Building a knowledge base of principles• Form family member

advisory boards• Invite family members to

present experiences at provider meetings

• Ensure family members are present as critical updates are shared

• Provide family education and support resources and referrals

Knowledge Base

A knowledge base is a collection of organized facts, rules and procedures

Knowledge base has a description of the elements in the process along with their characteristics, functions, and relationships

Also contains rules about actions to implement as a result of certain events

NAMI Family-to-Family (FTF) Education Program

FTF is a 12-week course offered by the National Alliance on Mental Illness (NAMI) for family members of adults with mental illness.

Rigorous research evaluated the course's effectiveness.

Dixon, L. B., Lucksted, A., Medoff, D. R., Burland, J., Stewart, B., Lehman, A. F., … Murray-Swank, A. (2011). Outcomes of a Randomized Study of a Peer-Taught Family-to-Family Education Program for Mental Illness. Psychiatric Services, 62(6), 591–597. https://doi.org/10.1176/ps.62.6.pss6206_0591

Study Outcomes

FTF Education Program

• Enhances the coping and empowerment of families members

• Indications of improved problem solving and reduction of distress

The role of social support in health and wellness

Lack of social support and frequent feelings of loneliness increase infection, illness, and death rates,1 as well as cognitive decline.2

1 Brummett et al., 2001; Pressman et al., 2005; Seeman, 2000); depression (Heikkinen & Kauppinen, 20042 Barnes, Mendes de Leon, Wilson, Bienias, & Evans, 2004; Wilson et al., 2007

The relationship between wellness and faith / spiritual principles

Faith communities’ unique role:• Clergy are on the front lines• Faith communities are more

numerous/accessible• They provide education and

social settings• They are committed to social

justice and caring• Faith is a key component in

coping and recovery

• Participate in faith/spiritual mental health training.

• Partner with local faith community as a resource.

Faith and wellness

Family-based approaches and family-centered

recovery supports

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Alcoholism and addiction have long been described as a “family disease”…

and yet……usually, services

focus on helping the individual.

The evolution of family-centered treatment

• Family-centered treatment for pregnant and parenting mothers with substance use disorders

• Family-centered treatment for adolescents

• Family-centered approaches in other service systems (e.g., behavioral health courts, children’s system of care, mental health)

• Recovery-oriented systems of care

How do we help families succeed?

• We used to think that just keeping the kids with their moms would be enough. That would keep women in treatment and all would be well in the family.

• We found that the children have needs of their own.

• We also learned about the role of trauma in parenting and its implications for healthy families.

TIP 39: Substance Abuse Treatment and Family Therapy.(2015). https://store.samhsa.gov/product/TIP-39-Substance-Abuse-Treatment-and-Family-Therapy/SMA15-4219

TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women (2015). https://store.samhsa.gov/product/TIP-51-Substance-Abuse-Treatment-Addressing-the-Specific-Needs-of-Women/SMA15-4426

Continuum of family services

5 - Family-based treatment

3 - Household Head’s and Children’s Services

2 - Programs for Household Head with Child Care

1 - Services for Individual, Family Involvement

0 -No Family Focus

4 - Family Services

Key assumptions for family-based care

• “Family” is important• Family members can help

and be helped• Families are diverse• Trauma informed care

benefits the whole family

Working with individuals in an integrated healthcare manner

person

family members

work/ school

health

home

legal

Recovery community

friends

person

family members

work/ school

health

homelegal

recovery community

friends

Working with a “small” family in an integrated healthcare manner

child

family members

work/ school

health

homelegal

recovery community

friends

partner

family members

work/ school

health

homelegal

recovery community

friends

A whole family approach includes…

• Reconnection • Communication skills/tools• Reducing stress burden• Mutual support and

integrated service plans• Mutual priorities and

community support plan• Building family strengths,

identity and cohesiveness• Recreation and leisure• Holidays

Werner, D., Young, N.K., Dennis, K, & Amatetti, S.. Family-Centered Treatment for Women with Substance Use Disorders – History, Key Elements and Challenges. SAMHSA, 2007. https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf

To improve outcomes for women

• For women, connections are a priority, a life motivator.

• Women are relational. Supportive relationships are essential. Engagement/retention improve when family is involved.

• For many women, being a mother is the most important identity.

• To support women often, the “glue” that holds the family together.

TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women (2015). https://store.samhsa.gov/product/TIP-51-Substance-Abuse-Treatment-Addressing-the-Specific-Needs-of-Women/SMA15-4426

Brady & Randall, 1999; Grella, Scott, & Foss, 2005; United Nations Office on Drugs and Crime, 2004

To foster resilience in children

• Needs are addressed• Families are strengthened• Social competence• Problem solving skills• Autonomy• Sense of purpose/future

Supporting Infants, Toddlers and Families Impacted by Caregiver Mental Health Problems, Substance Abuse, and Trauma: A Community Action Guide

Reducing stereotyping and discrimination for families in crisis Cause: yes, families think

they caused it.Control: families think they can control it, by vigilanceCure: families want to cure it by doing the right thing.

The Three C’s:

https://www.samhsa.gov/capt/tools-learning-resources/trauma-resilience-resources

To improve outcomes for family relationships

• Better parenting skills• Parent-child relationships• Attachment• Stability • Relationship satisfaction • Reunification• Reduced violence• Improved communicationWorking with the Community and Supporting Families https://ncsacw.samhsa.gov/resources/working-with-community.aspx

September 2016: Building Family Resiliency: Supporting Recovery. https://www.recoverymonth.gov/road-to-recovery/tv-series/september-2016-building-family-resiliency

To improve outcomes for the community• Cost savings from:

• improved employment • reduced criminal recidivism • improved prenatal and birth outcomes • reduced foster care costs• reduced school problems • future health costs

• Enabling people to contributeto their communities

Cheng, T. L., Johnson, S. B., & Goodman, E. (2016). Breaking the Intergenerational Cycle of Disadvantage: The Three Generation Approach. Pediatrics, 137(6), e20152467. http://doi.org/10.1542/peds.2015-2467

Think Family Toolkit: http://webarchive.nationalarchives.gov.uk/20130323053534/https://www.education.gov.uk/publications/eOrderingDownload/Think-Family.pdf

Questions DiscussionComments

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SAMHSA’s

10 Principlesand

4 Dimensionsof Recovery in

Behavioral Health

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HomeHealth

CommunityPurpose

Recovery to Practice

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Through education, training, and resources SAMHSA’sRecovery to Practice (RTP) program supports the expansion and integration of recovery-oriented behavioral health care delivered in multiple service settings between multiple disciplines.

Want to continue your learning?

1Integrated collaborative care teams to enhance service delivery to youth with mental health and substance use challenges: protocol for a pragmatic randomized controlled trial

2Consumer-centered, collaborative, and comprehensive care: the core essentials of recovery-oriented system of care

3 Family-focused practice in mental health care: An integrative review

4Using Peer Navigators to Address the Integrated Health Care Needs of Homeless African Americans With Serious Mental Illness

5 Religious Coping Among Adults Caring for Family Members with Serious Mental Illness

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