SOCW 6311 WK 2 ASSIGNMENT: Assignment: Evidence-Based Practice Implementation—Anticipating Results

Be sure to include APA in text citations and references.

Many social workers attempt to implement an evidence-based practice that seems to be strongly supported by research, only to become frustrated or confused when their efforts do not yield the same positive results as the research. This discrepancy can occur because they failed to recognize the differences between conditions in their practice environment and the conditions of the study. Moreover, they may have failed to consider and adequately plan for issues that arise during implementation.

To prepare for this Assignment, using the resources for evidence-based practices, identify an evidence-based practice that may be applicable to your field of practice. Review two research articles demonstrating the effectiveness of the evidence-based practice. Note any similarities or differences between the conditions in which the evidence-based practice was implemented in the study and the conditions in which you plan to implement it.

Submit a 4- to 5-page paper that analyzes the implementation of the evidence-based practice in your field of practice to determine if you can expect similar results to the research. The paper should include the following Must Start with introduction and end with conclusion And hits all these bullet points

MY SOCIAL WORK FIELD OF PRACTICE IS ADVANCED Clinical Practice

A description of the evidence-based practice that you selected including:

The population for which the evidence-based practice is intended

The problems for which the evidence-based practice is intended to address

A summary of the evidence from the research articles that demonstrate the evidence-based practice’s effectiveness

An explanation of any differences between the conditions of the study and the conditions on your practice. Explain the potential impact these differences could have on successful implementation.

A description of the steps that would be required to implement the evidence-based practice including:

Any factors that would support each step and how you would leverage them

Any factors that would limit or hinder each step and how you would mitigate them

A conclusion that includes:

Anticipated results of the implementation in your practice setting

An explanation of whether they will be similar or different from the research results from the articles

Resources 

Promising Practice Network.(N.D.).Programs that work. Retrieved from

http://www.promisingpractices.net/programs_indicator_list.asp?indicatorid=7

 

Promising Practice Network.(N.D.) Research in brief. Retrieved from

http://www.promisingpractices.net/issuebriefs.asp

 

Child Welfare Information Gateway. (N.D.) Evidence-based practice for child abuse prevention. Retrieved from

https://www.childwelfare.gov/topics/preventing/evidence/

 

Substance Abuse and Mental Health Services Administration. (2018) Evidence-based practice resource center. Retrieved from

https://www.samhsa.gov/ebp-resource-center

 

The Campbell Collaboration. (N.D.) Retrieved from

http://www.campbellcollaboration.org/

 

Getting Started

with Evidence-Based
Practices

Family

Psychoeducation

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

http://www.samhsa.go

Family
Psychoeducation
Getting Started
with Evidence-Based
Practices

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

Acknowledgments

This document was prepared for the Substance Abuse and Mental Health Services Administration
(SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number
280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Department
of Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served as
the Government Project Officers.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors and
do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services
(CMHS), SAMHSA, or HHS.

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced or
copied without permission from SAMHSA. Citation of the source is appreciated. However,
this publication may not be reproduced or distributed for a fee without the specific, written
authorization from the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, please
call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English
and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Family Psychoeducation: Getting
Started with Evidence-Based Practicess. HHS Pub. No. SMA-09-4422, Rockville, MD: Center for
Mental Health Services, Substance Abuse and Mental Health Services Administration,
U.S. Department of Health and Human Services, 2009.

Originating Office

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
Rockville, MD 20857

HHS Publication No. SMA-09-4422
Printed 2009

http://www.samhsa.gov/shin

Getting Started with
Evidence-Based Practices

Getting Started with EBPs

gives you an overview of the activities
that are generally involved in implementing EBPs and tells you
how to make EBPs culturally competent. This booklet is particularly
relevant to the following:

n  Mental health authorities; and

n  Agency staff who develop and manage EBP programs.

Family
Psychoeducation

For references, see the booklet The Evidence.

This KIT is part of a series of Evidence-Based Practices KITs created
by the Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration, U.S. Department of Health
and Human Services.

This booklet is part of the Family Psychoeducation KIT that includes
a DVD, CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Staff

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP

Family
Psychoeducation

What’s in Getting Started with
Evidence-Based Practices

Consensus Building: Build Support for Change . . . . . . . . 3

Integrate the EBP into Policies and Procedures . . . . . . . . 5

Assess Training Needs

. . . . . . . . . . . . . . . . . . . . . . . . . 7

Monitor and Evaluate Regularly

. . . . . . . . . . . . . . . . . . 9

Maximize Effectiveness by Making Services
Culturally Competent . . . . . . . . . . . . . . . . . . . . . . . . . 11

Getting Started with EBPs 3

Getting Started
with Evidence-Based Practices

Consensus Building:
Build Support for Change

Within a system, change affects
stakeholders differently. Consequently,
when making changes in the mental
health system, mental health agencies
should expect varied reactions from
staff, community members, consumers,
and families. Since misunderstandings
can stymie your efforts to implement
evidence-based practices (EBPs),
it is important to build consensus
to implement EBPs in the community.

Practitioner training alone is not
effective. The experience of mental
health authorities and agencies that have
successfully implemented EBPs reinforces
that fact. Instead, practitioner training

must be complemented by a broad range
of implementation activities, including the
following:

n Building support for the EBP;

n Integrating the EBP into agency
policies and procedures;

n Training staff agency-wide on basic EBP
principles; and

n Allowing for ongoing monitoring and
evaluation of the program.

This overview introduces the general
range of activities involved in successfully
implementing EBPs. For guidelines and
suggestions for EBP-specific activities, see
the remaining sections of each KIT.

4 Getting Started with EBPs

How to build support for your EBP

Consensus-building activities are designed to build
support for implementing EBPs. Here are some
ways to develop them:

Step 1 Identify key stakeholders or people who
will be affected by the EBP. Stakeholders
may include agency personnel at all
levels, mental health authority staff, and
consumer and family representatives.
Depending on the EBP, you may also
wish to build relationships with other
community organizations, such as the
Department of Vocational Rehabilitation,
homeless shelters, food banks, police,
hospitals, peer-support programs, and
consumer and family groups.

Step 2 Invite one potential EBP champion from
each stakeholder group to participate in
an EBP advisory committee. According
to agencies that have successfully
implemented EBPs, identifying ongoing
champions and forming an advisory
committee are critical activities. While at
first you may feel that creating an advisory
committee slows the process, any amount
of time used to build stakeholder support is
worth the effort.

EBPs have little hope for success if the
community doesn’t recognize that they are
needed, affordable, worth the effort, and
congruent with community values and the
agency’s practice philosophy. Mental health
authorities and agency administrators must
convey to key stakeholders a clear vision
and a commitment to implementing the
EBP. By forming an advisory committee
of potential champions from each
stakeholder group, you will be able to

broadly disseminate information in the
community. After training committee
members in the basic principles of the EBP,
ask them to hold informational meetings
or to regularly disseminate information to
their stakeholder groups.

Step 3 Ask for advice. Developing the advisory
committee and educating its members
in the EBP early in the planning process
will allow you to ask committee members
for their advice during all phases of the
implementation process. Community
members may help assess how ready
the community and the agency are to
implement the EBP and its activities.
Once the EBP is in place, committee
members can keep EBP staff informed of
relevant community trends that may have
an impact on providing the EBP services.

EBP advisory committees are crucial
for sustaining the EBP over time. When
EBP staff turn over, or other well-trained
staff leave and must be replaced, or when
funding streams or program requirements
change, community and political alliances
are essential. A well-established committee
can champion the EBP through changes.

Step 4 Build an action plan. Once key
stakeholders basically understand the EBP,
have your advisory committee develop an
action plan for implementation. Action
plans outline activities and strategies
involved in developing the EBP program,
including the following:

n    Integrating the EBP principles into
mental health authority and agency
policies and procedures;

n  Outlining initial and ongoing training
plans for internal and external
stakeholders; and

Getting Started with EBPs 5

n    Designing procedures to regularly
monitor and evaluate the EBP.

Base the activities in your action plan on
the needs of the population you serve, your
community, and your organization.

Step 5 Involve the advisory committee in an
ongoing evaluation of the EBP. Committee
members can help you decide which
outcomes you should target. They can
help you integrate continuous quality
improvements.

Integrate the EBP into Policies
and Procedures

Examine policies and procedures

Mental health authorities and agencies that have
successfully implemented EBPs highlight the
importance of integrating the EBP into policies and
procedures. For example, you will immediately face
decisions about staffing the EBP program. Mental
health authorities can support the implementation

 

To start implementing your EBP

n   Pinpoint key stakeholder groups that will be
affected by implementing the EBP.

n   Identify potential champions from each group
and invite them to participate in an EBP
advisory committee.

n  Ask the committee to advise you during
the process.

n Build an action plan.

n Outline responsibilities for committee members,
such as:

  o Participating in EBP basic training;

  o   Providing basic information about the EBP to
their stakeholder groups;

  o   Advising you during all phases of the
implementation process; and

  o   Participating in an ongoing evaluation
of the EBP.

6 Getting Started with EBPs

process by integrating staffing criteria into
regulations. Agency administrators should select
an EBP program leader and practitioners based
on mental health authority regulations and
qualifications that the EBP requires. New EBP
position descriptions should be integrated into
the agency’s human resource policies. EBP-
specific suggestions in Building Your Program
will help mental health authorities and agency
staff determine the appropriate mix and number
of staff, define staff roles, and develop a
supervision structure.

Agency administrators and mental health
authorities should also review administrative
policies and procedures to ensure that they are
compatible with EBP principles. For example,
you may need to modify admission and discharge
assessment, treatment planning, and service-
delivery procedures. Make sure policies and
procedures include information about how to
identify consumers who are most likely to benefit
from the EBP and how to integrate inclusion
and exclusion criteria into referral mechanisms.
Integrating EBP principles into policies and
procedures will build the foundation of the
EBP program and will ensure that the program
is sustainable. Examine policies and procedures
early in the process. While most changes will occur
in the planning stages, regularly monitoring and
evaluating the program (see discussion below)
will allow you to periodically assess the need for
more changes.

Identify funding issues

Identifying and addressing financial barriers is
critical since specific costs are associated with
starting new EBP programs and sustaining them.
Identify short- and long-term funding mechanisms
for EBP services, including federal, state, local
government, and private foundation funds. You can
work with your EBP advisory committee to project
start up costs by identifying the following:

n  Time for meeting with stakeholders that is not
reimbursed;

n Time for staff while in training;

n Staff time for strategic planning;

n Travel to visit other model EBP programs; and

n  Costs for needed technology (cell phones and
computers) or other one-time expenses accrued
during the initial implementation effort.

You should also identify funding mechanisms for
ongoing EBP services and to support continuous
quality improvement efforts, such as ongoing
training, supervision, technical assistance, fidelity,
and outcomes monitoring. In addition, you may
need to revise rules for reimbursement that are
driven by service definitions and criteria; this may
require interagency meetings on the federal, state,
and local levels.

Getting Started with EBPs 7

 

Get these valuable resources to help implement your EBP

Numerous materials are available through the U.S. Department of Health and Human Services
(http://www.hhs.gov) about using Medicaid and Medicare to fund necessary services. If you are
implementing EBPs, one useful resource is Using Medicaid to Support Working Age Adults with Serious
Mental Illnesses in the Community: A Handbook, published by the Assistant Secretary of Planning and
Evaluation, January 2005.

http://aspe.hhs.gov/daltcp/reports/handbook

This handbook gives you an excellent introduction to the Medicaid program, including essential features,
eligibility, and coverage of mental health services, community services, and waivers. It also provides helpful
information for states seeking Medicaid funding to implement the following:

n Family Psychoeducation;

n Assertive Community Treatment;

n Illness Management and Recovery;

n Integrated Treatment for Co-Occurring Disorders;

n Medication Management;

n Supported Employment;

n Supportive Housing;

n Consumer-Directed Services; and

n Peer Support.

Assess Training Needs

One of the next steps in implementing your
EBP is to develop a training plan. You may gauge
the amount of training needed by assessing the
readiness of your community. If a community
doesn’t know about the EBP and doesn’t recognize
the existing need, you may have to conduct a wide
range of educational activities. If a community
already understands the EBP and knows how it may
address problems that community members want
to solve, you may need fewer educational activities.

You can help train key stakeholder groups if
you first train members of your EBP advisory
committee and then ask them to disseminate
information about the purpose and benefits
of the EBP.

In addition to assessing training needs in the
community, agency administrators should gauge
how well staff across the agency understand the
EBP. Agency administrators who have successfully
implemented EBPs highlight the importance of
providing basic training on the EBP to all levels
of staff throughout the agency. Educating and
engaging staff will ensure support for the EBP.
In the long run, if they are well trained, EBP
staff will have an easier time obtaining referrals,
collaborating with staff from other service
programs, and facilitating a continuum of care.

Ongoing in-service training is an efficient way to
provide background information, the EBP practice
philosophy and values, and the basic rationale
for EBP service components in a comfortable
environment. Consider including members of
your advisory committee in decisions about the
frequency and content of basic EBP training.

http://www.hhs.gov

http://aspe.hhs.gov/daltcp/reports/handbook

8 Getting Started with EBPs

Offer more intensive training to program
leaders and practitioners

While staff at all levels in the agency should
receive basic EBP training, the program leader and
practitioners will require more intensive training.
To help practitioners integrate EBP principles
into their daily practice, offer comprehensive
skills training to those who provide EBP services.
Each KIT contains a variety of EBP-specific
training tools to help you provide both basic and
intensive training.

Although most skills that practitioners need may
be introduced through these training tools, research
and experience show that the most effective way to
teach EBP skills is through on-the-job consultation.
Consultants may provide comprehensive training
and case consultation to EBP practitioners.

Consultants may also help mental health authorities
and agency administrators to do the following:

n Provide basic information to key stakeholders;

n Assess the community’s readiness for change;

n   Assist in integrating EBP principles into policies
and procedures; and

n Design ongoing training plans.

In many mental health agencies, turnover of
staff is high. This means that the EBP will not
be sustained unless ongoing training is offered to
all employees.

Many agencies have also found it useful for
program leaders and practitioners to become
familiar with the structure and processes of the
practice by visiting agencies that have successfully
implemented the EBP.

Early in the process, mental health authorities
and agency administrators must decide how to
accomplish the following:

n    Identify internal and external stakeholders who
will receive basic training;

n   Determine how often basic training will be
offered;

n   Identify who will provide the training;

n   Identify EBP staff and advisory group members
who will receive comprehensive skills training;

n   Determine the training format for ongoing
training to EBP staff; and

n   Determine whether EBP staff may visit a model
EBP program.

EBP-specific suggestions in Building Your Program
will help mental health authorities and agency staff
develop an EBP training plan.

Getting Started with EBPs 9

Monitor and Evaluate Regularly

Key stakeholders who implement EBPs may find
themselves asking two questions:

n Has the EBP been implemented as planned?

n Has the EBP resulted in the expected
outcomes?

Asking these two questions and using the answers
to improve your program is a critical component
for ensuring the success of your EBP.

n   To answer the first question, collect process
measures (by using the EBP Fidelity Scale and
General Organizational Index). Process measures
capture how services are provided.

n   To answer the second question, collect outcome
measures. Outcome measures capture the results
or achievements of your program.

As you prepare to implement an EBP, we strongly
recommend that you develop a quality assurance
system using both process and outcome measures
to monitor and improve the program’s quality from
the startup phase and continuing through the life
of the program. Evaluating Your Program in the
KIT contains an EBP-specific Fidelity Scale, the
General Organizational Index, and sample outcome
measures. These measures may be integrated
into existing quality assurance programs or help
agencies develop new ones.

Why you should collect process measures

Process measures, such as the EBP Fidelity Scale
and General Organizational Index, help you assess
whether the core elements of the EBP were put
into place in your agency. Research tells us that
the higher an agency scores on a fidelity scale, the
greater the likelihood that the agency will achieve
favorable outcomes (Becker et al., 2001; Bond &
Salyers, 2004). For this reason, it is important to
monitor both fidelity and outcomes.

Process measures give agency staff an objective,
structured way to determine if you are delivering
services in the way that research has shown will
result in desired outcomes. Collecting process
measures is an excellent method to diagnose
program weaknesses, while helping to clarify
program strengths. Process measures also give
mental health authorities a comparative framework
to evaluate the quality of EBPs across the state.
They allow mental health authorities to identify
statewide trends and exceptions to those trends.

Why you should collect outcome measures

While process measures capture how services
are provided, outcome measures capture the
program’s results. Every service intervention has
both immediate and long-term consumer goals.
In addition, consumers have goals for themselves,
which they hope to attain by receiving mental
health services. These goals translate into outcomes
and the outcomes translate into specific measures.

10 Getting Started with EBPs

Some outcomes directly result from an
intervention, such as getting a job by participating
in a supported employment program. Others are
indirect, such as improving consumers’ quality of
life as a result of having a job. Some outcomes are
concrete and observable, such as the number of
days worked in a month. Others are subjective,
such as being satisfied with EBP services.

Therefore, you should collect outcome
measures, such as homelessness, hospitalization,
incarceration, and recovery, that show the effect
that services have had on consumers, in addition
to the EBP fidelity measures. Monitoring fidelity
and outcomes on an ongoing basis is a good
way to ensure that your EBP is effective.

 

Developing a quality assurance
system will help you

n   Diagnose your program’s strengths
and weaknesses;

n   Formulate action plans to improve the
program;

n   Help consumers achieve their goals for
recovery; and

n   Deliver mental health services both efficiently
and effectively.

How process and outcome data improve EBPs

Collecting and using process and outcome
data can improve consumer participation and
staff performance.

Consider the following story:

Participants in a partial hospitalization program
sponsored by a community mental health center
consistently showed very little vocational interest or
activity. Program staff began gathering data monthly
about consumers’ vocational status and reporting the
data to their program consultant. Every 3 months, the
consultant returned the data to them using a simple
bar graph.

The positive result of gathering and using information
about consumers’ vocational activity was evident
almost immediately. Three months after starting this
monitoring system, the percentage of the program’s
consumers who showed an interest or activity in
vocational areas increased from 36% to 66%. Three
months later, 72% of program participants were
involved in some form of vocational activity.

This example shows that sharing process and
outcomes data with consumers can stimulate
participation in your EBP program.

Similarly, disseminating assessment data can
enhance the performance of EBP staff and increase
motivation, professional learning, and a sense
of accomplishment. In their study of successful
companies, Peters and Waterman (1982) observed:

We are struck by the importance of available
information as the basis for peer comparison.
Surprisingly, this is the basic control mechanism
in the excellent companies. It is not the military
model at all. It is not a chain of command wherein
nothing happens until the boss tells somebody to
do something. General objectives and values are set
forward and information is shared so widely that
people know quickly whether or not the job is getting
done — and who’s doing it well or poorly (p. 266).

Information in Evaluating Your Program will teach
quality assurance team members how to collect,
analyze, and use process and outcomes data to
improve their EBP program.

Getting Started with EBPs 11

Maximize Effectiveness
by Making Services
Culturally Competent

Cultural competence is an approach to delivering
services that assumes that services are more
effective when they are provided within the most
relevant and meaningful cultural, gender-sensitive,
and age-appropriate context for the people
being served.

You can improve the quality of your EBP program
by ensuring that it is culturally competent — that
it adapts to meet the needs of consumers from
diverse cultures. First, it is important to understand
what culture and cultural competence are and how
they affect care.

What culture is and how it affects care

Broadly defined, culture is a common heritage or
set of beliefs, norms, and values that a group of
people shares. People who are placed — either by
census categories or by identifying themselves —
into the same racial or ethnic group are often
assumed to share the same culture; however, not all
members who are grouped together will share the
same culture.

A great diversity exists within each broad category.
Some individuals may identify with a given racial
or ethnic culture to varying degrees, while others
may identify with multiple cultures, including those
associated with their religion, profession, sexual
orientation, region, or disability status.

Culture is dynamic. It changes continually and
is influenced both by people’s beliefs and by the
demands of their environment. Immigrants from
different parts of the world arrive in the United
States with their own culture but gradually begin
to adapt and develop new, hybrid cultures that
allow them to function in the dominant culture.
This process is called acculturation. Even groups
that have been in the U.S. for many generations
may share beliefs and practices that maintain

influences from multiple cultures. This complexity
necessitates an individualized approach to
understanding culture and cultural identity in
the context of mental health services.

Culture influences many aspects of care,
starting with whether people think care is
even needed. Culture influences the concerns
that people bring to the clinical setting, the
language they use to express those concerns,
and the coping styles they adopt.

Culture affects family structure, living
arrangements, and the degree of support that
people receive in time of difficulties. Culture
also influences patterns of help-seeking, whether
people start with a primary care doctor, a mental
health program, or a minister, spiritual advisor, or
community elder. Finally, culture affects whether
people attach a stigma to mental health problems
and how much trust they place in the hands
of providers.

Culture isn’t just a consumer issue

It’s easy to think that culture belongs only to
consumers without realizing how it also applies to
providers and administrators. Professional culture
influences how providers and administrators
organize and deliver care. Some cultural influences
are more obvious than others — such as the manner
in which practitioners ask questions or how they
interact with consumers. Less obvious but equally
important are issues such as the following:

n The operating hours of an agency;

n   The importance that staff attaches to reaching out
to family members and community leaders; and

n   The respect that staff gives to the culture of
consumers who enter their doors.

Knowing how culture influences so many aspects
of mental health care underscores the importance
of adapting agency practices to respond to,
and be respectful of, the diversity of the
surrounding community.

12 Getting Started with EBPs

The need for cultural competence

For decades, many mental health agencies
neglected to recognize the growing diversity
around them. Often, people from non-majority
cultures found programs off-putting and hard to
access. They avoided getting care, stopped looking
for care, or — if they managed to find care — they
dropped out.

Troubling disparities resulted. Many minority
groups faced lower access to care, lower use of care,
and poorer quality of care. Disparities were most
apparent for racial and ethnic minority groups,
such as the following:

n African Americans;

n American Indians and Alaska Natives;

n Asian Americans;

n Hispanic Americans; and

n     Native Hawaiians and other Pacific Islanders.

But disparities also affect many other groups,
such as the following:

n Women and men;

n Children and older adults;

n People from rural areas;

n People of different religions;

n People with different sexual orientations; and

n People with physical or developmental
disabilities.

Altogether, those disparities meant that millions
of people suffered needless disability from
mental illnesses.

Starting in the late 1980s, the mental health
profession responded to the issue of disparity with
a new approach to care called cultural competence.
Originally cultural competence was defined as a
set of congruent behaviors, attitudes, and policies
that come together in a system, agency, or among
professionals to enable people to work effectively

in cross-cultural situations. Cultural competence is
intended to do the following:

n 

n 

n   

Improve consumers’ access to care;

Build trust; and

Promote consumers’ engagement and retention
in care.

What is cultural competence?

In the Surgeon General’s report on the topic
cultural competence, it is defined in the most
general terms as

“… the delivery of services responsive to the cultural
concerns of racial and ethnic minority groups,
including their languages, histories, traditions,
beliefs, and values” (U.S. Department of Health and
Human Services, 2001).

In most cases, cultural competence refers to sets of
guiding principles developed to increase the ability
of mental health providers, agencies, or systems to
meet the needs of diverse communities, including
racial and ethnic minorities.

While consumers, families, providers, policymakers,
and administrators have long acknowledged the
intrinsic value of cultural competence, insufficient
research has been dedicated to identifying its key
ingredients. Therefore, the field still struggles to
define cultural competence, put it into operation,
and measure it.

The word competence is somewhat misleading.
It usually implies a set of criteria on which to
evaluate a program. But this is not yet true;
cultural competence is still underresearched.
In this context, competence means that the
responsibility to tailor care to different cultural
groups belongs to the system, not to the consumer.
Every provider or administrator who is involved
in delivering care — from mental health
authorities down to clinical supervisors and
practitioners — bears responsibility for trying to
make programs accessible, appropriate, appealing,
and effective for the diverse communities
that they serve. Many do it naturally.

Getting Started with EBPs 13

How cultural competence
relates to EBPs

According to the Surgeon General, evidence-based
practices are intended for every consumer who
enters care, regardless of his or her culture. But
programs often need to adjust EBPs to make them
accessible and effective for cultural groups that
differ in language or behavior from the original
study populations. The adjustments should help,
rather than interfere with, a program’s ability to
implement EBPs using the KITs.

In a nutshell, to deliver culturally competent
EBPs, you must tailor to the unique communities
you serve either the practice itself or the context
in which the practice is delivered. In time, specific
fidelity measures may be available to assess a
program’s cultural competence, but not yet. The
evidence base is too small.

While the evidence is being collected, programs
can and should tailor EBPs to each cultural
group they serve, for instance, by translating
their informational brochures into the languages
often used in their communities. For more
suggestions, see How to put cultural competence
into practice.

Many providers ask,

How can we know if EBPs apply to a particular
ethnic, racial, or cultural group if the research
supporting those practices was done on a very
different population?

The answer is that we will not know for sure
until we try; but the limited research that
does exist suggests that EBPs, perhaps with
minor modifications, work well across cultures.
Furthermore, because EBPs represent the highest
quality of care currently available, it is a matter of
fairness and prudence to provide them to all people
who may need them. Yet the question remains,
How can we do this effectively?

How to put cultural competence
into practice

Since the goal is for all programs to be culturally
competent, we offer a variety of straightforward
steps to help agency administrators respond
more effectively to the people they serve. These
steps apply to all facets of a program; they are
not restricted to the EBP program alone. Please
note that the following guidelines are meant to be
illustrative, not prescriptive:

n   Understand the racial, ethnic, and cultural
demographics of the population served.

n   Become most familiar with one or two of the
groups you most commonly encounter.

n   Create a cultural competence advisory committee
consisting of consumers, family, and community
organizations.

n Translate your forms and brochures.

n   Offer to match a consumer with a practitioner
who has a similar background.

n   Use bilingual staff, including those trained in
American Sign Language, when needed. If
this is not possible, then have ready access to
qualified interpreters.

n   Ask consumers about their cultural backgrounds
and identities.

n   Incorporate cultural awareness into consumers’
assessment and treatment.

n   Tap into natural networks of support, such as
the extended family and community groups that
represent the consumer’s culture.

n   Reach out to religious and spiritual organizations
to encourage referrals or as another network
of support.

n   Offer training to staff in culturally responsive
communication or interviewing skills.

n   Understand that some behaviors that one culture
may consider to be signs of psychopathology are
acceptable in a different culture.

n   Be aware that consumers from other cultures
may hold different beliefs about causes and
treatment of illness.

14 Getting Started with EBPs

How mental health authorities
can help

We offer you a few examples of how public
mental health authorities can help develop a more
culturally competent mental health system:

n   Designate someone with part-time or full-time
responsibility for improving and monitoring
cultural competence.

n   Create a strategic plan to incorporate cultural
competence into the mental health system.

n   Establish an advisory committee that includes
representatives from all the major racial, ethnic,
and cultural groups you serve.

n   Address barriers to care (including cultural,
linguistic, geographic, or economic barriers).

n   Promote staffing that reflects the composition of
the community you serve.

n   Promote regular organizational self-assessments
of cultural competence.

n   Collect and analyze data to examine disparities in
services.

n   Designate specific resources for cultural
competence training.

n   Include cultural competence in quality-assurance
and quality-improvement activities.

For more suggestions about adapting EBPs to
diverse groups, see the remaining booklets in
the KIT.

A look at cultural competence
through five vignettes

Vignette — Integrated Treatment for
Co-Occurring Disorders

Kevin is a 40-year-old African American homeless
man in Chicago who, for a decade, cycled between
jail, street, and shelter. At the shelter, he refused
help for what the staff believed was a longstanding
combination of untreated schizophrenia and
alcoholism.

He became so drunk one night that he walked in
front of a car and was seriously injured. While in the
hospital, he was treated for his injuries, as well as
placed on anti-psychotic medications after psychiatrists
diagnosed him with schizophrenia.

When he was discharged from the hospital, Kevin
was referred to an integrated treatment program
for co-occurring disorders. Realizing that Kevin
needed aggressive treatment to avoid spiraling into
homelessness again, the head of the treatment team
recommended concurrently treating the alcoholism
and schizophrenia. The integrated treatment
specialist was an African American psychiatrist who
appreciated the years of alienation, discrimination,
and victimization that Kevin described as having
contributed to his co-occurring disorders.

The integrated treatment specialist worked hard to
develop a trusting relationship. He worked with the
treatment team to ensure that, in addition to mental
health and substance abuse treatment, Kevin received
social skills training and a safe place to live. When
Kevin was well enough, and while he continued
receiving group counseling for his co-occurring
disorders, one of his first steps toward recovery was to
reconnect with his elderly mother who had not heard
from him in 10 years.

Getting Started with EBPs 15

Vignette — Assertive Community Treatment

A minister in Baltimore contacted the city’s Assertive
Community Treatment (ACT) program with an unusual
concern: one of his congregants disclosed to him
that another member of the congregation — an
older woman from Jamaica — was beating her adult
daughter for “acting crazy all the time.” The Jamaican
mother might even be locking her adult daughter in
the basement, according to the congregant.

One year before, an ACT team member had reached
out to local ministers to tell them about the program.
The ACT team had realized that better communication
and referrals were needed. Stronger connections
across organizations would improve chances for
recovery by enhancing social support and adherence
to treatment. Some consumers, however, believed that
treatment was against their religion.

The ACT team member obtained a court order to
allow authorities to enter the Jamaican mother’s
home. They discovered the traumatized 25-year-old
daughter locked in the basement, actively psychotic,
and bearing marks of physical abuse. The team
diagnosed the daughter with schizophrenia and
arranged housing for her.

The team arranged for an intense combination
of medications and individual and group therapy,
including trauma care and social skills training.
Through links to the church and the community,
the team helped the daughter get clothing and
spiritual support.

The team discovered that the mother’s ethnic
group from Jamaica believed that her daughter’s
mental illness was a sign of possession by the devil.
The team reached out to the mother to educate her
about schizophrenia and to set the stage for the
daughter’s eventual return to her mother’s household.

Vignette — Illness Management and Recovery

Lupita, a 17-year-old high school senior, arrived in
an emergency room after a suicide attempt. The
psychiatrist on call happened to be the same one who
had diagnosed Lupita’s bipolar disorder a year before.
He thought that she had been taking her medications
properly, but blood tests now revealed no trace of
psychiatric medication.

The psychiatrist tried to communicate with Lupita’s
anxious parents who were waiting in the visitor
area, only to learn that they spoke only Spanish,
not English. The psychiatrist had mistakenly assumed
that because Lupita, a second-generation Mexican
American, was highly acculturated, so were her
parents. She contacted the hospital’s bilingual Illness
Management and Recovery (IMR) practitioner who
learned that the parents felt powerless for months
as they watched their daughter sink into a severe
depression.

The IMR practitioner, whose family had similarly
emigrated from a rural region of Mexico, knew
to gently ask the parents if they could read and
understand the dosage directions for Lupita’s
medication. Finding that the parents had limited
literacy in both English and Spanish, they tailored the
treatment program so that it would not depend on
the written word. They also introduced Lupita and
her family to the IMR program. The hospital had
organized programs for Spanish-speaking families
because of the large number of Latinos in the area.

During the weekly sessions, the IMR practitioner
translated for the family and helped them schedule
Lupita’s psychiatric visits. Together they apportioned
the correct combination of pills in a daily pill
container. Understanding that the family had no
phone, the IMR practitioner worked with them to find
a close neighbor who might allow them to use the
phone to relay messages from her and to contact her
if Lupita stopped taking her medications.

16 Getting Started with EBPs

Vignette — Family Psychoeducation

In times of difficulties, many Native Hawaiians rely on
their elders, traditional healers, families, or teachers
to provide them with wisdom and cultural practices to
resolve problems. One such practice is ho`oponopono,
which is a traditional cultural process for maintaining
harmonious relationships among families through
a structured discussion of conflicts. Ho`oponopono
is also used by people for personal healing and
guidance in troubled times.

When Kawelo lost his job as an electrician, his mental
health practitioner asked him if he had a family elder
who knew of community elders who were familiar
with traditional Hawaiian healing practices. Kawelo’s
practitioner recognized the importance of tapping into
this community support and suggested that his family
seek out ho`oponopono.

Kawelo and his practitioner contacted the family and
elders to arrange a meeting. At the meeting, the
practitioner provided information about Kawelo’s
illness. They discussed symptoms and warning signs of
relapse.

The therapist asked the elders how the group could
support Kawelo’s recovery. After lengthy deliberations,
the family decided that one way to help Kawelo was to
participate in ho’oponopono to understand the types
of problems that he was experiencing and identify
how the family could help him heal himself. Some
members of the family also agreed to participate in
a Family Psychoeducation (FPE) program to learn
more about his mental illness and ways to support his
recovery.

Through the FPE program, the family participated in
structured multi-family group sessions. Because an
important level of healing in Native Hawaiian culture
involves sharing positive and negative emotions in an
open, safe, and controlled environment, the family’s
participation in a combination of ho’oponopono
and FPE was successful in helping Kawelo.

Vignette — Supported Employment

Jing is a bilingual employment specialist. By
informally surveying her caseload, she estimates
that about 30% of the consumers with whom she
works are Asian, but they come from vastly different
backgrounds, ranging from Taiwan to Cambodia, with
different educational levels.

One of the consumers with bipolar disorder with
whom she works recently immigrated from China.
He has a high school education, but speaks Mandarin
and very little English. Fluent in Mandarin, Jing is able
to conduct a careful assessment of the consumer’s job
skills and a rapid, individualized job search.

Jing identifies several import-export businesses in
the area that have monolingual Mandarin-speaking
employees. She and the consumer secure a position,
but it pays less than one the consumer would qualify
for if he spoke English. Jing and the consumer
decide to take the position while, at the same time,
participating in a quick-immersion night program in
English as a Second Language.

Jing provides follow-along job support during the next
few months. When the consumer’s English is better,
Jing and the consumer search for and find a higher
paying job. Jing continues follow-along services to
support the consumer in his adjustment to the greater
demands of the new position.

Getting Started with EBPs 17

Selected resources on cultural competence

The following resources on cultural competences
apply to all EBPs. These resources are for
consumers and families, mental health authorities,
administrators, program leaders, and practitioners.
For resources related to each EBP, see The
Evidence in each KIT.

National resources for consumers
and families

Center for Mental Health Services
Substance Abuse and Mental Health Services
Administration
SAMHSA’s Health Information Network
Rockville, MD
Phone: 1-877-SAMHSA-7 (1-877-726-4727)
(English and Español)
http://www.samhsa.gov/shin

First Nations Behavioral Health Confederacy
Phone: (406) 732-4240 Montana
Phone: (505) 275-3801 Albuquerque, NM
pauletterunningwolf@hotmail.com

National Alliance on Mental Illness (NAMI)
Colonial Place Three
2107 Wilson Boulevard, Suite 300
Arlington, VA 22201-3042
Phone: (800) 950-NAMI (6264)
Fax: (703) 524-9094
TTY: (703) 516-7227

Homepage

National Asian American Pacific Islander
Mental Health Association
1215 19th Street, Suite A
Denver, CO 80202
Phone: (303) 298-7910
Fax: (303) 298-8081
http://www.naapimha.org

National Institute of Mental Health (NIMH)
Office of Communications
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: (866) 615-NIMH (6464)
Fax: (301) 443-4279
TTY: (301) 443-8431
http://www.nimh.nih.gov

National Latino Behavioral Health Association
P.O. Box 387
506 Welch, Unit B
Berthoud, CO 80513
Phone: (970) 532-7210
Fax: (970) 532-7209

Home Page

National Leadership Council on African American
Behavioral Health
6904 Tulane Drive
Austin, TX 78723-2823
Phone: (512) 929-0142
Fax: (512) 471-9600

Home

Mental Health America
2001 North Beauregard Street, 6th Floor
Alexandria, VA 22311
Phone: (800) 969-6642
Phone: (703) 684-7722
Fax: (703) 684-5968
TDD: (800) 433-5959
http://www.nmha.org

Resources for mental health authorities

Aponte, C., & Mason, J. (1996). A demonstration
project of cultural competence self-assessment
of 26 agencies. In M. Roizner, A practical
guide for the assessment of cultural competence
in children’s mental health organizations
(pp. 72-73). Boston: Judge Baker Children’s
Center.

http://www.samhsa.gov/shin

mailto:pauletterunningwolf@hotmail.com

Homepage

http://www.naapimha.org

http://www.nimh.nih.gov

Home Page

Home

http://www.nmha.org

18 Getting Started with EBPs

California Mental Health Ethnic Services
Managers with the Managed Care Committee.
(1995). Cultural competency goals, strategies
and standards for minority health care to
ethnic clients. Sacramento: CA: Mental Health
Directors’ Association.

Carpinello, S. E., Rosenberg, L., Stone, J.,
Schwager, M., and Felton, C. J. (2002). Best
practices: New York State’s campaign to
implement evidence-based practices for people
with serious mental disorders. Psychiatric
Services, 53(2), 153-5.

Chorpita, B. F., & Nakamura, B. J. (2004). Four
considerations for dissemination of intervention
innovations. Clinical Psychology: Science and
Practice, 11, 364-367.

Dillenberg, J., & Carbone, C. P. (1995). Cultural
competency in the administration and delivery of
behavioral health services. Phoenix, AZ: Arizona
Department of Health Services.

Knisley, M. B. (1990). Culturally sensitive language:
community certification standards. Columbus,
OH: Ohio Department of Mental Health.

National Implementation Research Network.
(2003). Consensus statement on evidence-based
programs and cultural competence. Tampa, FL:
Louis de la Parte Florida Mental Health Institute.

New York State Office of Mental Health. (1998).
Cultural competence performance measures for
managed behavioral healthcare programs. Albany,
NY: New York State Office of Mental Health.

New York State Office of Mental Health.
(1998). Final Report: Cultural and Linguistic
Competency Standards. Albany, NY: New York
State Office of Mental Health.

Pettigrew, G. M. (1997). Plan for culturally
competent specialty mental health services.
Sacramento, CA: California Mental Health
Planning Council.

Phillips, D., Leff, H. S., Kaniasty, E., Carter,
M., Paret, M., Conley, T., & Sharma, M.
(1999). Culture, race and ethnicity (C/R/E)
in performance measurement: A compendium
of resources; Version 1. Cambridge, MA: The
Human Services Research Institute (Evaluation
Center@HSRI).

Siegel, C., Davis-Chambers, E., Haugland, G.,
Bank, R., Aponte, C., & McCombs, H. (2000).
Performance measures of cultural competency in
mental health organizations. Administration and
Policy in Mental Health, 28, 91–106.

U.S. Department of Health and Human Services.
(1996). Consumer mental health report card.
Final report: task force on a consumer-oriented
mental health report card. Rockville, MD:
Substance Abuse and Mental Health Services
Administration.

U.S. Department of Health and Human Services.
(2000). Cultural competence standards in
managed mental health care services: Four
underserved/underrepresented racial/ethnic
groups. HHS Pub. No. SMA 00-3457. Rockville,
MD: Center for Mental Health Services,
Substance Abuse and Mental Health Services
Administration.

U.S. Department of Health and Human Services.
(1999). Mental health: A report of the Surgeon
General. Rockville, MD: U.S. Department of
Health and Human Services, Substance Abuse
and Mental Services Administration, Center for
Mental Health Services, National Institutes of
Health, National Institute of Mental Health.

Western Interstate Commission for Higher
Education (WICHE) and Human Services
Research Institute (The Evaluation Center@
HSRI). (1999). Notes from a roundtable
on conceptualizing and measuring cultural
competence. Boulder, CO: WICHE Publications.

Getting Started with EBPs 19

Western Interstate Commission for Higher
Education (WICHE). (1997). Cultural
competence standards in managed mental health
care for four underserved/ under represented
racial/ethnic groups. Boulder, CO: WICHE
Publications.

Center for Mental Health Services
Substance Abuse and Mental Health Services
Administration
SAMHSA’s Health Information Network
Rockville, MD
Phone: 1-877-SAMHSA-7 (1-877-726-4727)
(English and Español)
http://www.samhsa.gov/shin

Hogg Foundation for Mental Health
The University of Texas at Austin
P.O. Box 7998
Austin, TX 78713-7998
Phone: (800) 404-4336
Fax: (512) 471-5041

Hogg Foundation for Mental Health

Resources for mental health administrators

Lopez, L., Jackson, V. H. (1999). Cultural
competency in managed behavioral healthcare:
An overview. In V. H. Jackson, L. Lopez
(Eds.). Cultural competency in managed
behavioral healthcare. Providence, RI: Manisses
Communications Group, Inc.

Center for Mental Health Services
Substance Abuse and Mental Health Services
Administration
SAMHSA’s Health Information Network
Rockville, MD
Phone: 1-877-SAMHSA-7 (1-877-726-4727)
(English and Español)
http://www.samhsa.gov/shin

Human Services Research Institute
2336 Massachusetts Avenue
Cambridge, MA 02140
Phone: (617) 876-0426
http://www.hsri.org

National Alliance of Multi-Ethnic Behavioral
Health Associations
1875 I Street, NW
Suite 5009
Washington, DC 20006
Phone: (202) 429-5520
http://www.nambha.org

National Center for Cultural Competence
Georgetown University Center for Child and
Human Development
3300 Whitehaven Street, NW
Suite 3300
Washington, DC 20057
Phone: (202) 687-5387
TTY: (202) 687-5503

Western Interstate Commission for
Higher Education (WICHE)
Mental Health Program
P.O. Box 9752
Boulder, CO 80301-9752

Home

Resources for program leaders

Barrio, C. (2000). The cultural relevance of
community support programs. Psychiatric
Services, 51, 879–874.

Issacs, M. R., & Benjamin, M. P. (1991). Toward
a culturally competent system of care: programs
which utilize culturally competent principles.
Washington, DC: Georgetown University Child
Development Center.

http://www.samhsa.gov/shin

Hogg Foundation for Mental Health

http://www.samhsa.gov/shin

http://www.hsri.org

http://www.nambha.org

Home

20 Getting Started with EBPs

Leong, F. (1998). Delivering and evaluating mental
health services for Asian Americans. In Report of
the roundtable on multicultural issues in mental
health services evaluation. Tucson, AZ: Human
Services Research Institute (The Evaluation
Center,@HSRI).

Musser-Granski, J., & Carrillo, D. F. (1997). The
use of bilingual, bicultural paraprofessionals in
mental health services: issues for hiring, training,
and supervision. Community Mental Health
Journal 33, 51–60.

Phillips, D., Leff, H. S., Kaniasty, E., Carter,
M., Paret, M., Conley, T., & Sharma, M.
(1999). Culture, race and ethnicity (C/R/E) in
performance measurement: A compendium
of resources; Version 1. Cambridge, MA: Human
Services Research Institute (The Evaluation
Center@HSRI).

Ponterotto, J. G., & Alexander, C. M. (1996).
Assessing the multicultural competence of
counselors and clinicians. In L. A. Suzuki,
P. J. Meller, and J. G. Ponterotto (Eds.),
Handbook of multicultural assessment: clinical,
psychological, and educational applications (pp.
651–672). San Francisco: Jossey-Bass.

Tirado, M. D. (1996). Tools for monitoring cultural
competence in health care. San Francisco: Latino
Coalition for a Healthy California.

U.S. Department of Health and Human Services.
(1999). Mental health: A Report of the Surgeon
General. Rockville, MD: U.S. Department of
Health and Human Services, Substance Abuse
and Mental Health Services Administration,
Center for Mental Health Services, National
Institutes of Health, National Institute of
Mental Health.

U.S. Department of Health and Human Services.
(2001). Mental health: Culture, race, and
ethnicity. A supplement to mental health: A
report of the Surgeon General. Rockville, MD:
U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services
Administration, Center for Mental Health
Services.

Instruments to assess cultural competence

Consolidated Culturalogical Assessment
Toolkit (C-CAT)
Ohio Department of Mental Health, 2003.

n Measures cultural competence in mental health
systems and organizations

n Includes comprehensive training and
promotional materials

For more information:

http://www.ccattoolkit.org/C-CAT.shtml
Multiethnic Advocates for Cultural Competence
Columbus, OH 43215
Phone: (614) 221-7841
http://www.maccinc.net

Cross-Cultural Counseling Inventory (CCCI)

n Measures knowledge, attitudes, and beliefs
about cultural diversity

n Measures cross-cultural counseling skills

For more information:

LaFromboise, T., Coleman, H., Hernandez, A.
(1991). Development and factor structure of
the cross-cultural counseling inventory-revised.
Professional Psychology, Research and Practice
22 (5), 380–388.

http://www.maccinc.net

http://www.ccattoolkit.org/C-CAT.shtml

Getting Started with EBPs 21

Cultural Acceptability of Treatment Survey (CATS)
Human Services Research Institute (HSRI), 1998.

n Measures the cultural competency of services

n Measures organizational accommodations
and practices

n Measures consumer preferences and satisfaction

For more information:

Human Services Research Institute
2336 Massachusetts Avenue
Cambridge, MA 02140
Phone: (617) 876-0426
Fax: (617) 492-7401
http://www.hsri.org

Cultural Competency Assessment Scale (CCAS)
Nathan S. Kline Institute for Psychiatric

Research, 2000.

n Assesses organization’s level of cultural
competence

n Consistent with EBP fidelity instruments

For more information:

Nathan S. Kline Institute for Psychiatric Research
140 Old Orangeburg Road
Orangeburg, NY 10962
Phone: (845) 398-5500
Fax: (845) 398-5510
http://www.rfmh.org/nki/

Multicultural Counseling Awareness Scale (MCAS)

n Assesses cultural awareness, knowledge,
and skills

n Self-report of 45 items

For more information:

Ponterotto, J. G., Alexander, C. M. (1996)
Assessing the multicultural competence of
counselors and clinicians in L. A. Suzuki,
P. J. Meller, J. G. Ponterotto (Eds.) Handbook of
multicultural assessment: Clinical, psychological,
and educational applications (pp. 651–672) San
Francisco: Jossey-Bass.

Multicultural Counseling Inventory (MCI)

n Assesses awareness, knowledge, skills,
and relations

n Self-report of 43 items

For more information:

Sodowsky, G. R., Taffe, R. C., Gutkin, T. B.,
Wise, S. L. (1994). Development of the
multicultural counseling inventory: a self-
report measure of multicultural competencies.
Journal of Counseling Psychology 41, 137–148.

Resources for practitioners

Aguirre-Molina M., Molina, C. W., & Zambrana
R. E. (Eds.) (2001). Health issues in the Latino
community. San Francisco, CA: John Wiley &
Sons, Inc.

Alvidrez, J. (1999). Ethnic variations in mental
health attitudes and service among low-income
African American, Latina, and European
American young women. Community Mental
Health Journal, 35, 515–530.

American Psychiatric Association. (2000). Appendix
I: Outline for cultural formulation and glossary
of culture-bound syndromes. In Diagnostic
and statistical manual of mental disorders,
Fourth Edition, Text Revision (DSM-IV-TR).
Washington, DC: Author.

Aranda, M. P. (1990). Culture friendly services for
Latino elders. Generations 14, 55–57.

Atkinson, D. R., Morten, G., & Sue, D. (1983).
Counseling American minorities. Dubuque, IA:
Wm. C. Brown.

Atkinson, D. R., & Gim, R. H. (1989). Asian-
American cultural identity and attitudes toward
mental health services. Journal of Counseling
Psychology, 36, 209–213.

http://www.hsri.org

http://www.rfmh.org/nki/

22 Getting Started with EBPs

Baldwin, J. A., & Bell, Y. (1985). The African Self-
Consciousness Scale: An Afrocentric personality
questionnaire. The Western Journal of Black
Studies 9, 61–68.

Bauer, H., Rodriguez, M. A., Quiroga, S.,
Szkupinkski, S., & Flores-Ortiz, Y. G. (2000).
Barriers to health care for abused Latina and
Asian immigrants. Journal of Health Care for the
Poor and Underserved, 11, 33–44.

Belgrave, F. Z. (1998). Psychosocial aspects of
chronic illness and disability among African
Americans. Westport, CT: Auburn House/
Greenwood Publishing Group, Inc.

Berkanovic, E. (1980). The effect of inadequate
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Engineering, 58, 3916.

Branch C. & Fraser, I. (2000). Can cultural
competency reduce racial and ethnic health
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Browne, C. T. (1986). An anguished relationship:
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with serious mental illness: Building hope.
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Carter, R. T., & Qureshi, A. (1995). A typology
of philosophical assumptions in multicultural
counseling and training. In J. G. Ponterotto, J.
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The Chinese Culture Connection. (1987). Chinese
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Cuellar, I., Harris, C., & Jasso, R. (1980). An
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Dana, R. H. (1998). Understanding cultural
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Davies, J., McCrae, B. P., Frank, J., Dochnahl,
A., Pickering, T., Harrison, B. et al. (1983).
The influence of client-clinician demographic
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Feliz-Ortiz, M., Newcomb, M. D., & Meyers, H.
(1994). A multidimensional measure of cultural
identity for Latino and Latina adolescents.
Hispanic Journal of Behavioral Sciences, 16,
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Gallimore, R. (1998). Accommodating cultural
differences and commonalities in research
and practice. In Report of the roundtable on
multicultural issues in mental health services
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Gaw, A. C. (Ed.) (1993). Culture, ethnicity, and
mental illness. Washington, DC: American
Psychiatric Press.

Getting Started with EBPs 23

Gaw, A. C. (Ed.) (2001). Concise guide to cross-
cultural psychiatry. Washington, DC: American
Psychiatric Press.

Gilvarry, C. M., Walsh, E., Samele, C., Hutchinson,
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24 Getting Started with EBPs

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26 Getting Started with EBPs

Cultural Adaptation Pain Scale (CAPS)

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A. (1996). Assessing cultural adaptation:
psychometric properties of the cultural
adaptation pain scale. Journal of Multicultural
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Cultural Information Scale (CIS)

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99–115.

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(MRIS)-Revised

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Research in Personality 29 (1995): 208–222.

Multigroup Ethnic Identity Measure (MEIM)

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Measure: A new scale for use with adolescents
and young adults from diverse groups. Journal of
Adolescent Research, 7, 156–176.

Suinn-Lew Asian Self-Identity Acculturation Scale
(SL-ASIA)

Suinn, R. M., Richard-Figueroa, K., Lew, S., &
Vigil, P. (1987). The Suinn-Lew Asian Self-
Identity Acculturation Scale: An Initial Report.
Educational and Psychological Assessment, 47,
401–407.

Short Acculturation Scale for Hispanics (SASH)

Marin, G., Sabogal, F., Van Oss Marin, B.,
Otero-Sabogl, R., & Perez-Stable, E. (1987).
Development of a short acculturation scale
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Sciences, 9, 183–205.

White Racial Identity Attitude Scale (WRIAS)

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of the White Racial Identity Inventory. In J. E.
Helms (Ed.) Black and White racial identity:
Theory, research, and practice (pp. 67–80).
New York: Greenwood Press.

HHS Publication No. SMA-09-4422
Printed 2009

25268.0709.7765020404

• Cover
• Title Page

Acknowledgments
Getting Started with EBPs

• Consensus Building: Build Support for Change

How to build support for your EBP

• Integrate the EBP into Policies and Procedures

Examine policies and procedures
Identify funding issues
Assess Training Needs
Offer more intensive training to program leaders and practitioners
Monitor and Evaluate Regularly
Why you should collect process measures
Why you should collect outcome measures
How process and outcome data improve EBPs

• Maximize Effectiveness by Making Services Culturally Competent

What culture is and how it affects care
Culture isn’t just a consumer issue
The need for cultural competence
What is cultural competence?
How cultural competence relates to EBPs
How to put cultural competence into practice
How mental health authorities can help
A look at cultural competence through five vignettes
Vignette – Integrated Treatment for CoOccurring Disorders
Vignette – Assertive Community Treatment
Vignette – Illness Management and Recovery
Vignette – Family Psychoeducation
Vignette – Supported Employment
Selected resources on cultural competence
National resources for consumersand families
Resources for mental health authorities
Resources for mental health administrators
Resources for program leaders
Instruments to assess cultural competence
Resources for practitioners
Scales for practitioners to recognize cultural identity

Family
Psychoeducation

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

Building
Your Program

http://www.samhsa.gov

Family
Psychoeducation

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services
Building
Your Program

Acknowledgments

This document was prepared for the Substance Abuse and Mental Health Services Administration
(SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number
280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Department
of Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served as
the Government Project Officers.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors and
do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services
(CMHS), SAMHSA, or HHS.

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced
or copied without permission from SAMHSA. Citation of the source is appreciated. However,
this publication may not be reproduced or distributed for a fee without the specific, written
authorization from the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, please
call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English
and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Family Psychoeducation: Building
Your Program. HHS Pub. No. SMA-09-4422, Rockville, MD: Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration, U.S. Department of Health and
Human Services, 2009.

Originating Office

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
Rockville, MD 20857

HHS Publication No. SMA-09-4422
Printed 2009

http://www.samhsa.gov/shin

For references, see the booklet The Evidence.

Building Your Program

Building Your Program is intended to help mental health
authorities, agency administrators, and family intervention
coordinators think through and develop the structure of
Family Psychoeducation programs. The first part of this
booklet gives you background information about the
evidence-based model. This section is followed by specific
information about your role in implementing and sustaining
your program. Although you will work closely together
to build your program, for ease, we separated tips into
two sections:

n Tips for Mental Health Authorities; and

n  Tips for Agency Administrators and Family
Intervention Coordinators.

In preparing this information, we could think of no one better
to advise you than people who have worked successfully
with Family Psychoeducation programs. Therefore, we based
the information in this booklet on the experience of veteran
family intervention coordinators and administrators.

Family
Psychoeducation

This KIT is part of a series of Evidence-Based Practices KITs created
by the Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration, U.S. Department of Health
and Human Services.

This booklet is part of the Family Psychoeducation KIT that includes
a DVD, CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Staff

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP

What’s in Building Your Program

What Is Family Psychoeducation?

. . . . . . . . . . . . . . . . . 1

Tips for Mental Health Authorities

. . . . . . . . . . . . . . . . 9

Tips for Agency Administrators
and Family Intervention Coordinators . . . . . . . . . . . . . 19

Family
Psychoeducation

Building Your Program 1 What Is Family Psychoeducation?

Family Psychoeducation (FPE) is an
approach for partnering with consumers
and families to treat serious mental
illnesses. FPE practitioners develop
a working alliance with consumers
and families.

The term psychoeducation can be
misleading. While FPE includes many
working elements, it is not family therapy.
Instead, it is nearly the opposite. In family
therapy, the family itself is the object of
treatment. But in the FPE approach,
the illness is the object of treatment, not
the family. The goal is that practitioners,
consumers, and families work together
to support recovery.

Serious mental illnesses such as
schizophrenia, bipolar disorder, and
major depression are widely accepted
in the medical field as illnesses with well-
established symptoms and treatment.
As with other disorders such as diabetes
or hypertension, it is both honest and
useful to give people practical information
about their mental illnesses, how common
they are, and how they can manage them.

Building Your Program
What Is Family Psychoeducation?

What Is Family Psychoeducation? 2 Building Your Program

Many consumers and families report that this
information is helpful because it lets them know
that they are not alone and it empowers them to
participate fully in the recovery process. Similarly,
research shows that consumer outcomes improve
if families receive information and support (Dixon
et al., 2001). For this reason, a number of family
psychoeducation programs have been developed
over the past two decades.

Models differ in their format (whether they
use a multifamily or single-family format);
duration of treatment; consumer participation;
and location. Research shows that the critical
ingredients of effective FPE include the following
(Dixon et al., 2001):

n Education about serious mental illnesses;

n Information resources, especially during periods
of crises;

n Skills training and ongoing guidance about
managing mental illnesses;

n Problem solving; and

n Social and emotional support.

The phases of Family
Psychoeducation

FPE services are provided in three phases:

n Joining sessions;

n An educational workshop; and

n Ongoing FPE sessions.

Joining sessions

Initially, FPE practitioners meet with consumers
and their respective family members in introductory
meetings called joining sessions. The purpose of
these sessions is to learn about their experiences
with mental illnesses, their strengths and resources,
and their goals for treatment.

FPE practitioners engage consumers and families
in a working alliance by showing respect, building
trust, and offering concrete help. This working
alliance is the foundation of FPE services. Joining
sessions are considered the first phase of the
FPE program.

Building Your Program 3 What Is Family Psychoeducation?

Educational workshop

In the second phase of the FPE program, FPE
practitioners offer a 1-day educational workshop.
The workshop is based on a standardized
educational curriculum to meet the distinct
educational needs of family members.

FPE practitioners also respond to the individual
needs of consumers and families throughout
the FPE program by providing information and
resources. To keep consumers and families engaged
in the FPE program, it is important to tailor
education to meet consumer and family needs,
especially in times of crisis.

Ongoing Family Psychoeducation sessions

After completing the joining sessions and 1-day
workshop, FPE practitioners ask consumers and
families to attend ongoing FPE sessions. When
possible, practitioners offer ongoing FPE sessions
in a multifamily group format. Consumers and
families who attend multifamily groups benefit
by connecting with others who have similar
experiences. The peer support and mutual aid
provided in the group builds social support
networks for consumers and families who are often
socially isolated.

Ongoing FPE sessions focus on current issues that
consumers and families face and address them
through a structured problem-solving approach.
This approach helps consumers and families make
gains in working toward consumers’ personal
recovery goals.

FPE is not a short-term intervention. Studies
show that offering fewer than 10 sessions does not
produce the same positive outcomes (Cuijpers,
1999). We currently recommend providing FPE
for 9 months or more.

In summary, FPE practitioners provide information
about mental illnesses and help consumers
and families enhance their problem-solving,
communication, and coping skills. When provided
in the multifamily group format, ongoing FPE
sessions also help consumers and families develop
social supports.

Practice principles

FPE is based on a core set of practice principles.
These principles form the foundation of the
evidence-based practice and guide practitioners
in delivering effective FPE services.

What Is Family Psychoeducation? 4 Building Your Program

Practice Principles

Principle 1:

Consumers define
who family is.

In FPE, the term family includes anyone consumers identify as being
supportive in the recovery process. For FPE to work, consumers must
identify supportive people they would like to involve in the FPE program.
Some consumers may choose a relative. Others may identify a friend,
employer, colleague, counselor, or other supportive person.

Principle 2:

The practitioner-consumer-family
alliance is essential.

Consumers and families have often responded to serious mental illnesses
with great resolve and resilience. FPE recognizes consumer and family
strengths, experience, and expertise in living with serious mental illnesses.

FPE is based on a consumer-family-practitioner alliance. When forming
alliances with consumers and families, FPE practitioners emphasize that
consumers and families are not to blame for serious mental illnesses. FPE
practitioners partner with consumers and families to better understand
consumers and support their personal recovery goals.

Principle 3:

Education and resources help
families support consumers’
personal recovery goals.

Consumers benefit when family members are educated about mental
illnesses. Educated families are better able to identify symptoms, recognize
warning signs of relapse, support treatment goals, and promote recovery.
Provide information resources to consumers and families, especially during
times of acute psychiatric episodes or crisis.

Principle 4:

Consumers and families who
receive ongoing guidance and
skills training are better able to
manage mental illnesses.

Consumers and families experience stress in many forms in response to
mental illnesses. Practical issues such as obtaining services and managing
symptoms daily are stressors. Learning techniques to reduce stress
and improve communication and coping skills can strengthen family
relationships and promote recovery. Learning how to recognize precipitating
factors and prodromal symptoms can help prevent relapses. For more
information, see Training Frontline Staff in this KIT.

Principle 5:

Problem solving helps consumers
and families define and address
current issues.

Using a structured problem-solving approach helps consumers and families
break complicated issues into small, manageable steps that they may more
easily address. This approach helps consumers take steps toward achieving
their personal recovery goals.

Principle 6:

Social and emotional support
validates experiences and
facilitates problem solving.

FPE allows consumers and families to share their experiences and feelings.
Social and emotional support lets consumers and families know that they
are not alone. Participants in FPE often find relief when they openly discuss
and problem-solve the issues that they face.

Building Your Program 5 What Is Family Psychoeducation?

How we know that Family
Psychoeducation is effective

FPE is based on research that shows that
consumers and families who participated in the
components of the evidence-based model had 20
to 50 percent fewer relapses and rehospitalizations
than those who received standard individual
services over 2 years (Penn & Mueser, 1996; Dixon
& Lehman, 1995; Lam, Knipers, & Leff, 1993;
Falloon et al., 1999). Those at the higher end of this
range participated for more than 3 months.

Studies also show that FPE improved family well-
being (Dixon et al., 2001). Families reported a
greater knowledge of serious mental illnesses;
a decrease in feeling confused, stressed, and
isolated; and reduced medical illnesses and use
of medical care (Dyck, Hendryx, Short, Voss, &
McFarlane, 2002).

FPE has been found to increase consumers’
participation in vocational rehabilitation programs
(Falloon & Pederson, 1985). Studies have shown
employment rate gains of two to four times baseline
levels, when combined with evidence-based
practice Supported Employment (McFarlane,
Dushay, Stastny, Deakins, & Link, 1996; McFarlane
et al., 1995; McFarlane et al., 2000).

Based on this significant evidence, treatment
guidelines recommend involving families in
the treatment process by offering the critical
ingredients outlined in this evidence-based model
(Lehman & Steinwachs, 1998; American Psychiatric
Association, 1997; Weiden, Scheifler, McEvoy,
Allen, & Ross., 1999).

Who benefits most from Family
Psychoeducation?

The greatest amount of research has shown benefits
for consumers with schizophrenic disorders and
their families (Dixon et al., 2001). Studies also show
promising results for the following illnesses:

n Bipolar disorder—(Clarkin, Carpenter, Hull,
Wilner, & Glick, 1998; Miklowitz & Goldstein,
1997; Moltz, 1993; Parikh et al., 1997; Miklowitz
et al., 2000; Simoneau, Miklowitz, Richards,
Saleem, & George, 1999);

n Major depression—(Simoneau et al., 1999;
Emanuels-Zuurveen & Emmelkamp, 1997; Leff
et al., 2000);

n Obsessive-compulsive disorder—(Van Noppen,
1999); and

n Borderline personality disorder—(Gunderson,
Berkowitz, & Ruizsancho,, 1997).

Studies show that the effectiveness of FPE does
not differ depending on consumers’ age, gender,
education-level, or severity of illness.

This model has also been adapted and used
effectively with a number of ethnic groups in a
variety of settings in the United States. Studies have
also been conducted in the following countries:

n England—(Leff, Kuipers, Berkowitz, & Sturgeon,
1985; Leff et al., 1990; Tarrier et al., 1989);

n Spain—(Muela Martinez & Godoy Garcia, 2001;
Montero, Gomez-Beneyto, Ruiz, Puche, &
Adam, 1992; Tomaras et al., 2000);

n Germany—(Wiedemann et al., 2001); and

n China—(Xiong et al., 1994; Zhang, Wan, Li, &
Phillips, 1994).

What Is Family Psychoeducation? 6 Building Your Program

Although more replications are desirable, all the
evidence to date suggests that the positive effects
of FPE generalize to nearly all major cultural
populations: British, American, Australian, African
American, Spanish or Latino, Scandinavian
or Northern European, Chinese, and Japanese.
However, anecdotally we know that culture and
language pose significant barriers to providing
FPE in some populations and, in any case, require
culturally sensitive adaptations that must be further
explored empirically.

Is Family Psychoeducation for the family’s
benefit or for the consumer’s?

FPE is for both consumers and families. The
goal is to support recovery from serious mental
illnesses. The evidence-based model asks family
members to help in that effort. Though it is
designed to achieve clinical outcomes and recovery
goals for consumers, beneficial effects have been
found for families as well.

What if consumers do not have family
or do not want their families involved?

In FPE, the term family includes anyone
consumers identify as being supportive in the
recovery process. The broad definition emphasizes
that consumers choose whether to involve family
and whom to involve. FPE helps consumers
develop or enhance their support networks.

The evidence-based model has been found to work
well with consumers who are disengaged from
their families and have difficult treatment histories.
Joining sessions give practitioners the opportunity
to help consumers engage family members again
in a constructive and supportive manner.

Research shows that practitioners often ask
consumers for permission to involve their family
members during a crisis (Marshall & Solomon,
2003). Asking for family involvement at this
time may raise suspicions for some consumers.
Consequently, they may be more reluctant
to identify supportive people. For this reason,
modify your intake and assessment procedures
so that consumers are routinely told about the FPE
program and are periodically asked if they would like
to involve someone supportive in their treatment.
For more detail, see Set up referral procedures
under Tips for Agency Administrators and Family
Intervention Coordinators in this booklet.

If consumers do not wish to involve family
members in their treatment, FPE practitioners
should respect their decision. If consumers do not
give permission to share confidential information
with their families, FPE practitioners may still
respond to families’ questions and concerns.
Even the strictest interpretation of confidentiality
policies does not prohibit receiving information
from families or giving them general information
about serious mental illnesses and agency services
(Bogart & Solomon, 1999; Zipple, Langle, Spaniol,
& Fisher, 1997).

If families want to learn more about serious mental
illnesses, FPE practitioners should direct them
to local family organizations such as the National
Alliance on Mental Illness (NAMI). Consumers
who are not interested in FPE may benefit from
other education and skills training programs that
are targeted specifically to consumers such as
Illness Management and Recovery. For more
information, see the Illness Management and
Recovery KIT.

Building Your Program 7 What Is Family Psychoeducation?

Where should Family
Psychoeducation be provided?

The FPE multifamily group model was first
developed in a partial hospital setting. Nearly
all of the controlled research on effectiveness
has been conducted in outpatient clinics and
community mental health centers. The extent to
which FPE can be successfully adapted to other
types of agencies is unknown.

FPE has been successfully implemented in both
urban and rural settings, as well as in mid-sized
cities and suburbs. For more information, see
The Evidence in this KIT.

Is it cost effective?

Implementing an FPE program has initial costs
related to training and program development.
However, studies show a low cost-benefit ratio
related to savings from reduced hospital admissions,
hospital days, and crisis intervention contacts
(McFarlane, Dixon, Lukens, & Lucksted, 2003).

Cost-benefit ratios vary by state. For example, in
New York, for every $1 in costs for FPE provided
in a multifamily group format, a $34 savings in
hospital costs occurred during the second year of
treatment (McFarlane, 2002). In a hospital setting
in Maine, an average net savings occurred of $4,300
per consumer each year over 2 years. Ratios of $1
spent for this service to $10 in saved hospitalization
costs were routinely achieved.

Non-fiscal savings are achieved as complaints from
families about services decrease and family support
for the agency and the mental health authority
grows. In many communities, this has translated
into political support for funding for expanded
and improved services.

Building Your Program 9

Tips for Mental Health Authorities

The Family Psychoeducation (FPE) KIT
gives public mental health authorities a
unique opportunity to improve clinical
services for adults with serious mental
illnesses. Research has shown that FPE
has a consistent, positive impact on the

lives of consumers and their families.
The FPE KIT gives you information and
guidance for implementing this evidence-
based practice in a comprehensive and
easy-to-use format.

Building Your Program
Tips for Mental Health Authorities

Successfully implementing evidence-based practices requires the leadership
and involvement of mental health authorities. This section discusses why
mental health authorities should be involved in implementing Family
Psychoeducation and the types of activities that mental health authorities
typically undertake.

Why should you be interested in Family Psychoeducation?

Tips for Mental Health Authorities 10 Building Your Program

How can mental health
authorities support Family
Psychoeducation?

As you read about FPE, you may think that
it sounds great but unaffordable. We want to
challenge that notion because mental health
systems with limited resources are in the process
of implementing FPE programs system-wide.
These systems have visionaries who recognized
the benefits of providing this evidence-based
practice and who persisted in overcoming
challenges. We hope you are that visionary
for your system.

Implementing this evidence-based model takes a
consolidated effort by agency staff, mental health
authorities, consumers, and families. However,
for this initiative to be successful, mental health
authorities must lead and be involved in developing
FPE programs in local communities.

 

Be Involved in Family Psychoeducation

Step 1 Create a vision by clearly articulating
evidence-based practice principles
and goals. Designate a staff person to
oversee your FPE initiative.

Step 2 Form advisory groups to build
support, plan, and provide feedback for
your FPE initiative.

Step 3 Establish program standards
that support implementation. Make
adherence to those standards part of
licensing criteria.

Step 4 Address financial issues and align
incentives to support implementation.

Step 5 Develop a training structure tailored
to the needs of different stakeholders.

Step 6 Monitor fidelity and outcomes
to maintain and sustain program
effectiveness.

Building Your Program 11 Tips for Mental Health Authorities

Create a vision

Agencies commonly set out to implement
one program, but end up with something
entirely different. Sometimes these variations
are intentional, but often they occur for the
following reasons:

n One administration starts an initiative and
another with a different vision and priorities
subsequently assumes leadership.

n The model wasn’t clearly understood from
its inception.

n The staff drifted back to doing things in a way
that was more familiar and comfortable.

Articulating the vision that providing FPE helps
families and consumers recover from mental
illnesses is essential for successfully implementing
an FPE program. Place the FPE initiative in
the context of the larger recovery paradigm.
Talk about how FPE programs help agencies
fulfill their mission—assisting consumers in their
recovery process.

To ensure that your vision is clearly communicated,
designate a staff person who has experience with
the evidence-based model to oversee your FPE
initiative. Some mental health authorities designate
an office or staff with whom agencies may consult
throughout the process of building and sustaining
their FPE programs. Designated staff may also
have oversight responsibility for FPE programs
across the state.

Form advisory groups

You can ensure that the FPE model is implemented
appropriately if you contractually mandate
that stakeholder advisory groups guide the
implementation initiative. Your FPE initiative
can benefit in many ways from an advisory group.
Among other things, an advisory group can help
you do the following:

n Build internal and external support;

n Increase program visibility; and

n Seek advice about ongoing planning efforts.

Consider forming both local and state-level advisory
groups. State-level advisory groups may include the
following members:

n Representatives of state agencies that would be
invested in the initiative;

n Leadership from implementing agencies; and

n Representatives from consumer and family
advocacy organizations.

Local advisory groups can serve as liaisons between
the community and agencies that are implementing
FPE programs. Community stakeholders who have
an interest in the success of FPE programs include
the following:

n Local consumer organizations;

n Local family organizations;

n Agency administrators; and

n FPE practitioners.

Tips for Mental Health Authorities 12 Building Your Program

Facilitating your advisory group

From the beginning, lead your advisory groups
in understanding and articulating what FPE
is and how it is going to be developed in your
mental health system. For training materials that
you can use to help stakeholders develop a basic
understanding of FPE, see Using Multimedia to
Introduce Your EBP in this KIT.

Advisory groups should continue to meet well
after you have established your FPE program.
We suggest that they meet about once a month for
the first year, once every 2 months for the second
year, and quarterly for the third year. In the second
and third years, advisory groups may help FPE
programs sustain high fidelity by assisting with
fidelity evaluations and outcomes monitoring or
translating evaluation data into steps for continuous
quality improvement. For more information about
the role of advisory groups, see Getting Started
with EBPs in this KIT.

Planning your Family
Psychoeducation initiative

With a vision firmly in place, the process of
unfolding FPE programs across the service system
can begin. Carefully planning this process will
help ensure a successful outcome. Implementing
FPE programs first in pilot or demonstration
sites may be useful. Working with pilot sites can
help you manage problems as they arise and
also give constituents the opportunity to see that
the evidence-based model works. Multiple pilot
sites are preferable to just one. When only one
site is used, idiosyncratic things can happen that
misrepresent the model. In contrast, when mental
health authorities do a system-wide rollout, it is
difficult to adequately train all FPE program staff.
In that case, system problems that may have been
resolved easily on a smaller scale with a few FPE
programs can cause havoc.

Establish program standards

Studies of agencies that have tried to replicate
evidence-based practices have found that agencies
that did not achieve positive outcomes failed to
implement all of the components of the evidence-
based model (Becker et al., 2001; Bond & Salyers,
2004). As a mental health authority, you can ensure
that the system has incentives to implement the
evidence-based model as outlined in the FPE
Fidelity Scale (see Monitor fidelity and outcomes
below). Attention to aligning these incentives in a
positive way (such as attaching financial incentives
to achieving improved outcomes) is vital to
successfully implementing FPE programs.

States have the authority to adopt regulations that
govern services to consumers. These regulations set
standards for the quality and adequacy of programs,
including criteria that govern these areas:

n Admission and discharge;

n Staffing;

n Service components;

n Program organization and communication;

n Consumer medical records;

n Consumer rights; and

n Supervision and program evaluation.

Support FPE implementation by explicitly referring
to the evidence-based model in licensing standards
and other program review documents (for example,
grant applications, contracts, and requests for
proposals). Review current administrative rules and
regulations to identify any barriers to implementing
programs. Work closely with agency administrators
to ensure that state-level policies support high-
fidelity practice.

Building Your Program 13 Tips for Mental Health Authorities

Definition of FPE Services

The following language has been used to reimburse FPE services in Maine.

Cover

ed services include Family
Psychoeducation provided in multifamily
groups and in single-family sessions.
Covered services include Family
Psychoeducation as defined under
program elements, provided to related
and non-related care-takers, as well as to
the eligible person. Covered services may
be provided to the participating people
with or without the eligible person being
present, if all other program requirements
and elements are being provided.

Program elements of the covered services
include joining sessions, usually involving
eligible Medicaid recipients and their
family member, who may meet separately
or together, depending on clinical
condition and other considerations to be
determined by the eligible provider. These
sessions focus on exploring the following:

n  Precipitants of current and/or past
acute episodes of illness;

n  Prodromal signs and symptoms;

n  Coping strategies and strengths;

n  Family and social supports;

n  Grief and mourning in relation to the
illness; and

n  Treatment goals and planning.

There may be three or more joining
sessions, as early in the course of an
episode or illness as possible.

Educational workshops involve
identified family members and, at
the determination of the practitioners
leading the workshop, eligible
Medicaid recipients. These workshops
offer extensive information about
the biological, psychological, and
social aspects of mental illnesses; the
nature, effects, and side effects of
psychiatric treatments; what families
can do to help recovery and prevent
relapse; and guidelines for managing
mental illnesses.

Ongoing Family Psychoeducation
sessions occur biweekly in a multifamily
or single-family format, usually with
the eligible Medicaid recipient present.
These sessions follow an empirically
tested format and focus on solving
problems that interfere with treatment,
illness and symptom management, and
coping skills. Case management may
also be provided during these sessions.

Tips for Mental Health Authorities 14 Building Your Program

Address financial issues

Each state is different. Typically, FPE programs
are funded by a combination of state mental
health dollars, Medicaid, and private insurance.
Funding approaches that have been used in some
states include the following:

n Reallocating some psychosocial or psychotherapy
services for FPE services;

n Adopting a case-rate approach where the agency
is reimbursed monthly for each consumer to
cover bundled direct and indirect costs; or

n Seeking Medicaid reimbursement.

In some states, Medicaid authorities support
funding for FPE because emergency room visits
and hospital admission costs are greatly reduced.
The following chart is an example of how FPE
has been defined for the purpose of Medicaid
reimbursement.

Develop a training structure

Agencies who implement evidence-based practices
are often challenged in their efforts because people
misunderstand the model or because they lack
information. It is important that key stakeholders
(consumers, families, and other essential
community members) and agency-wide staff
develop a basic understanding of FPE.

We encourage you to support agency administrators
in their efforts to develop a training structure
for implementing FPE. The training plan
should include basic training for key community
stakeholders including the following:

n Consumers;

n Families;

n Mental health authority representatives; and

n Staff from key community organizations.

The training plan should also include basic training
for staff at all levels within participating agencies
and intensive training for FPE practitioners (staff
who are designated to provide FPE services).

Some mental health authorities develop a few FPE
programs at a time so that staff from the first FPE
program can help train those in newly developed
programs. Generally, it takes about a year for staff
to feel confident providing the evidence-based
model, but this can vary depending on how much
structural change is needed. FPE practitioners who
are reluctant to accept new models can take longer
to change.

It may take 2 to 3 years for an agency to become
sufficiently proficient in the evidence-based model
before it can assume the added responsibility
of training other agencies’ FPE practitioners.
Agencies that have become training sites indicate
that involving their staff in training staff from new
FPE programs reinforces the practice principles
and their knowledge of the evidence-based model.

Building Your Program 15 Tips for Mental Health Authorities

Choose your trainer

Intensive training plans for FPE practitioners
may be designed in several different ways. The
first decision is related to who will conduct the
training. The family intervention coordinator (a
staff member who is designated to oversee FPE
programs) may facilitate the initial training for FPE
practitioners by using the training tools in Training
Frontline Staff in this KIT.

Some mental health authorities choose to hire
external trainers to train practitioners across
the state. Other mental health authorities have
established training centers or enhanced existing
education and training centers that offer education,
training, and ongoing consultation or supervision.

One successful strategy for training FPE
practitioners entails having new FPE practitioners
visit an existing, well-functioning, high-fidelity FPE
program to observe how the program works. New
FPE practitioners will benefit most from this visit if
they have a basic understanding of the FPE model.

Once trained, family intervention coordinators and
practitioners will be able to use the tools in Using
Multimedia to Introduce Your EBP in this KIT to
provide basic training to key stakeholders.

Offer ongoing training and consultation

Throughout the first year of your FPE program,
participating agencies should offer intermittent
booster training sessions to FPE practitioners.
After the first year, consider establishing an annual
statewide conference on the evidence-based model.

Routine onsite and telephone consultation is also
important, particularly for family intervention
coordinators, since leading an FPE program
requires a complex set of administrative and
clinical skills. For example, family intervention
coordinators provide clinical supervision, which
may require a shift in thinking from how services
were traditionally provided. Family intervention
coordinators have administrative responsibilities
such as preparing administrative reports,
developing policies and procedures, and hiring.

Perhaps more important, family intervention
coordinators are responsible for ensuring that the
FPE program operates with fidelity to the evidence-
based model, including ensuring the quality and
content of practitioner-consumer-family interactions
(See Monitor fidelity and outcomes on the next
page). It is very difficult for any family intervention
coordinator to grasp everything that has to be
learned in a brief time. Also, understanding what
must be done and translating that understanding
into action are different and equally difficult. Strong
daily leadership is essential to ensure that the FPE
model is faithfully carried out.

Tips for Mental Health Authorities 16 Building Your Program

For at least the first year after a new program has
started, family intervention coordinators need
someone who is experienced in the evidence-
based model to give ongoing consultation on
organizational and clinical issues. Consultation
ranges from advice on how to integrate evidence-
based practice principles into the agency’s policies
and procedures to consulting on cases. A state- or
county-wide coordinator who is experienced with
the evidence-based model can also help new FPE
programs through ongoing contact, assessment, and
troubleshooting.

Monitor fidelity and outcomes

Providing FPE involves incorporating a new
program into the service delivery system. The
best way to protect your investment is to make
certain that agencies actually provide services
that positively affect the lives of consumers on an
ongoing basis.

Programs that adhere more closely to the evidence-

based model are more effective than those that do

not follow the model. Adhering to the model is
called fidelity.

The FPE Fidelity Scale measures how well
programs follow key elements of the evidence-
based model. Research tells us that the higher an
agency scores on a fidelity scale, the greater the
likelihood that the agency will achieve the favorable
outcomes (Becker et al., 2001; Bond & Salyers,
2004). For this reason, it is important to monitor
both fidelity and outcomes.

As a central part of the initial planning process, you
must address how you will monitor the fidelity and
outcomes of FPE programs. Too many excellent
initiatives began with enthusiastic support but
floundered at the end of a year because they did
not plan how they would maintain the program.
Monitoring fidelity and outcomes on an ongoing
basis is a good way to ensure that your FPE
programs will continue to grow and develop. For
more information about monitoring fidelity and
outcomes, see Evaluating Your Program in this KIT.

Consider developing routine supervision and
evaluations of FPE programs. If state or county-
level monitoring is not possible, use strategies (for
example, rules, contracts, financial incentives) to
support fidelity and outcomes monitoring on the
local level or within individual agencies.

For the characteristics of an FPE program that
would have a perfect score on the FPE Fidelity
Scale, see the next page. For the entire FPE Fidelity
Scale, see Evaluating Your Program in this KIT.

Building Your Program 17 Tips for Mental Health Authorities

Characteristics of a Family Psychoeducation Program That Would Have a Perfect Score
on the FPE Fidelity Scale

Family intervention
coordinator

A designated clinical administrator oversees the FPE program and performs
specific tasks.

Session frequency Consumers and families participate every 2 weeks in FPE sessions.

Long-term FPE Consumers and families are provided with long-term FPE. At least one family member
for each consumer participates in FPE sessions for at least 9 months.

Quality of practitioner-
consumer-family alliance

FPE practitioners engage consumers and family members with warmth, empathy,
acceptance, and attention to individual needs and desires.

Detailed family reaction FPE practitioners identify and specify families’ reaction to their relative’s mental illness.

Precipitating factors FPE practitioners, consumers, and families identify and specify precipitating factors for
consumers’ mental illnesses.

Prodromal signs
and symptoms

FPE practitioners, consumers, and families identify and specify prodromal signs and
symptoms of consumers’ mental illnesses.

Coping strategies FPE practitioners identify, describe, clarify, and teach coping strategies.

Educational curriculum FPE practitioners use a standardized curriculum to teach families about
mental illnesses.

Multimedia education Consumers and family members receive educational materials about mental illnesses in
several formats (for example, paper, video, and Web sites).

Structured group sessions FPE practitioners follow a structured procedure in conducting multifamily
group sessions.

Structured problem solving FPE practitioners use a standardized approach to help consumers and families with
problem solving.

Stage-wise provision
of services

FPE services are provided in the following order:

n  Engagement;

n  Three or more joining sessions;

n  The educational workshop; and

n  Multifamily group sessions.

Assertive engagement
and outreach

FPE practitioners assertively engage all potential consumers and family members by
phone, by mail, or in person (in the agency or in the community) on an ongoing basis.

Building Your Program 19 Tips for Mental Health Authorities

Building Your Program

Tips for Agency Administrators
and Family Intervention Coordinators

Whether your agency is interested in enhancing an existing program or
developing a new program, you will need a broad range of activities to
successfully implement Family Psychoeducation. This section outlines the
range of implementation activities in which agency administrators and
family intervention coordinators are often involved.

Recruit your staff

Family Psychoeducation (FPE)
programs typically consist of two or more
practitioners and a family intervention
coordinator. Broadly speaking, you can
consider agency staff who are involved
in providing FPE as a team, including
the family intervention coordinator, FPE
practitioners, and the agency director.

Choose a family
intervention coordinator

It is important to hire or designate
a leader for your FPE program. We
suggest that FPE leaders (called family
intervention coordinators) are full-time
employees whose time is completely
dedicated to the FPE program.

Family intervention coordinators are often mid-
level managers who have the authority to make or
suggest administrative changes within the agency.
Successful family intervention coordinators have
authority and both administrative and clinical skills.

As part of their administrative responsibilities, they
undertake the following tasks:

n Develop and monitor FPE policies and
procedures such as the intake and engagement
process;

n Assign potential FPE consumers to FPE
practitioners;

n Monitor and adjust FPE practitioner caseloads;
and

n Arrange for training new FPE practitioners and
continuing education of existing FPE staff.

Along with the agency director, family intervention
coordinators are often responsible for hiring FPE
practitioners, monitoring the program’s fidelity
to the FPE model, and overseeing other quality
control and financial mechanisms.

As part of their clinical responsibilities, family
intervention coordinators provide weekly group
supervision and individual supervision as needed.
During supervisory sessions, family intervention
coordinators give FPE practitioners program
feedback. They also act as a liaison with other
agency coordinators and key stakeholders to
maintain support for the FPE program.

Because family intervention coordinators must
have an active role in setting up the structures and
processes needed to support the FPE program, you
should make the KIT available to candidates during
the hiring process so they understand what they
must do.

Select the best Family
Psychoeducation practitioners

FPE practitioners can come from a wide range of
clinical backgrounds, including the following:

n Social work;

n Occupational therapy;

n Counseling;

n Case management;

n Nursing;

n Psychology; and

n Psychiatry.

In some carefully supervised situations,
paraprofessionals working closely with a masters-
level clinician have effectively conducted FPE
sessions. However, some agencies have experienced
difficulty being reimbursed for services provided
by non-licensed staff. For this reason, review the
regulations of FPE funding mechanisms when you
make staffing decisions.

Success as an FPE practitioner appears to have
less to do with academic credentials and more
to do with personal style and philosophy. Positive,
high-energy, and enthusiastic people who have a
“can do” attitude tend to do well. We recommend
recruiting FPE practitioners who understand
serious mental illnesses, believe that consumers
can live full and productive lives in the community,
and believe that families can support the
recovery process.

Effective FPE practitioners are warm, kind, and
empathic. Good listening skills are important,
including the ability to reflect back what consumers
and families say and seek clarification when
necessary. Good eye contact, a ready smile, and
a good sense of humor are other helpful attributes
that put people at ease.

Building Your Program 21 Tips for Administrators and Coordinators

Specific teaching and facilitation skills are also
helpful. FPE practitioners must be able to structure
sessions that follow a predictable pattern. They
must also be able to establish clear objectives and
expectations, set goals, and follow through on
those goals.

Another important attribute for practitioners is
the ability to take a shaping approach to increasing
consumers’ knowledge and skills. Shaping means
that practitioners recognize that people often
need a significant period of time to learn new
information and skills. You must give consumers
positive feedback for their efforts and acknowledge
small successes along the way. Having a shaping
attitude means that you acknowledge and value
even very small steps and encourage consumers to
achieve their personal goals.

In addition, FPE practitioners must be able to
work both independently and as team members—
providing cross-coverage for consumers and
participating in group supervision.

Reflect your community’s cultural diversity

FPE teams should reflect the cultural diversity
of the communities in which they operate. More
important, FPE practitioners must be aware of
and sensitive to cultural differences and consumer
preferences. FPE teams should include bilingual
practitioners as needed to reflect the cultural
diversity of the communities in which they provide
services. If bilingual staff are not available, you
should provide translators as needed.

Having a balance of male and female FPE
practitioners may also be helpful. In addition, your
FPE program must have resources available to
allow practitioners to work with consumers who
have hearing and visual impairments.

Consider these hiring tips

Thoroughly check references for job candidates.
The best predictor of work performance is likely
to be candidates’ performance in previous jobs,
particularly jobs that required some of the same
skills and personal qualities that are desirable
for FPE practitioners. The family intervention
coordinator should talk to previous supervisors,
ask in detail about candidates’ previous work
responsibilities and performance, and seek opinions
about their capabilities.

Invite all candidates who are being seriously
considered for employment to spend a half-day or
more in your FPE program so that they can see
practitioners at work firsthand. Candidates can then
better evaluate how well they might fit in and will
be able to make a more informed decision about
taking the job.

This visit will also give FPE practitioners a chance
to talk with and observe candidates. Ask them to
offer their feedback during the hiring process. This
type of screening may help you weed out people
who may not be appropriate for your FPE program.

 

Requirements for FPE Practitioners

n Have specific knowledge of mental
illnesses

n Be willing and able to actively involve
consumers and families in making
decisions about their own treatment and
services

n Have strong clinical and rehabilitative
skills

n Be warm, kind, positive, empathic people
with good listening and teaching skills

n Be willing to work both independently
and collaboratively as a team

Tips for Administrators and Coordinators 22 Building Your Program

Build support for your program

Developing a successful FPE program depends
on the support and collaboration of a number of
stakeholders. Internally, it is important that the
director and staff across the agency understand and
support implementing FPE. Your program is more
likely to achieve high fidelity if the agency director
is informed and involved in the implementation
process from the start.

It is important that the agency director take the
lead in promoting the FPE program and addressing
any misconceptions. Articulate internal and
public support for the FPE program by telling
key stakeholders that consumers can recover
from mental illnesses and families can support
the recovery process. Inform key stakeholders
that the core components of FPE are linked to
positive consumer outcomes and emphasize the
importance of your FPE program by demonstrating
how practitioners help consumers get on with
life beyond illness to achieve their personal
recovery goals.

Once the agency director has articulated a clear
vision for implementing the evidence-based model,
continue to bolster internal support for your
program by giving all agency staff basic information.
For more information, see Develop a training plan
later in this booklet.

Form advisory committees

Forming a local advisory committee for your
FPE program is an effective way to gain key
stakeholders’ support. Identify community
stakeholders who have an interest in the success
of your FPE program to serve on your committee.
Committees often include the following people:

n Representatives from local consumer
organizations;

n Members of local family organizations such as
the National Alliance on Mental Illness (NAMI);

n Representatives from local mental health
authority;

n Representatives from local mental health
agencies;

n Key agency staff; and

n FPE practitioners.

To start, your mental health authority
representatives or agency director should voice
support for the FPE initiative. Next, provide basic
training to help advisory group members understand
the evidence-based model. Once established,
advisory groups may help implement your program
in a variety of ways. For more information, see
Getting Started with EBPs in this KIT.

Sustain support for your program

Building support for your FPE program should
be an ongoing effort. Once your program is
operational, find ways to recognize and reward
the achievements of FPE practitioners and
consumers. For example, organize meetings with
key stakeholders during which consumers share
their success stories and administrators highlight
staff achievements.

Another option is to sponsor a banquet to celebrate
your program’s accomplishments with consumers,
family members, policymakers, and agency staff
members. Banquets are particularly helpful if a
wide array of stakeholders (such as physicians,
administrators, and key public officials) attend.

Your agency director and family intervention
coordinator should meet regularly to review
program evaluation data, discuss roadblocks, and
plan ways to improve your FPE program. Building
support from internal staff and key community
stakeholders is essential to implementing an
effective FPE program.

Building Your Program 23 Tips for Administrators and Coordinators

Develop effective policies
and procedures

Starting a new FPE program means developing
policies and procedures that support the activities
of the FPE model.

Develop admission and discharge criteria

Set up a process to identify consumers who are
appropriate for your FPE program and acquaint
referral sources with your procedures. Initially
many agencies choose to offer FPE to consumers
with schizophrenic disorders since the evidence
for this model is strongest with this group. Once
practitioners have provided FPE services to
consumers with schizophrenic disorders and their
families, it relatively easy to modify your FPE
program to provide services to consumers who
have other diagnoses and their families. For more
information on adapting FPE for specific diagnoses,
see The Evidence in this KIT.

FPE is effective for a wide variety of consumers.
No evidence suggests that consumers’ race, gender,
or age is related to consumer and families’ ability
to benefit from FPE. In addition, consumers may
benefit from FPE regardless of how long they have
experienced symptoms of their mental illnesses.

Some evidence shows that FPE is particularly
beneficial for consumers and families with the
following characteristics (McFarlane, 2002):

n Consumers who have recently experienced their
first episode of mental illness or are early in the
course of illness;

n Consumers who are experiencing acute
psychiatric crisis;

n Consumers who experience frequent
hospitalizations or prolonged unemployment;

n Consumers or families who have asked to learn
more about serious mental illnesses;

n Families who have previously benefited from a
family education program and want to learn how
to better support their relative; or

n Families who are especially exasperated or
confused about the illness.

 

Agency Directors Can Lead
This Effort

n Articulate clear support for the FPE
program to internal staff and key
community stakeholders.

n Attend some FPE trainings, supervision,
and advisory group meetings.

n Meet monthly with the family
intervention coordinator to address
roadblocks to providing FPE.

n Facilitate ongoing planning and program
improvement efforts.

n Engage local and state mental health
authority representatives.

 

What Policies and Procedures
Should Cover

n Admission and discharge criteria

n Staffing criteria

n Service components

n Program organization and
communication

n Consumer records requirements

n Consumers’ rights

n Program and team member performance
evaluation

Tips for Administrators and Coordinators 24 Building Your Program

FPE is particularly effective in working with
families and consumers who are early in the course
of illness since most consumers and families report
the most extreme distress during this time. Often
in this early period, major rifts develop between
consumers and families that may exacerbate
symptoms and disability. FPE has prevented
and often healed those rifts, as participants stop
blaming themselves or one another and cooperate
to help in the overall treatment and rehabilitation
process. Consider targeting your FPE program to
consumers based on these criteria.

Defining family

Participating in FPE is the consumers’ choice. In
FPE, the term family includes anyone consumers
believe is supportive and would like to participate
in FPE. For FPE to work, consumers must identify
supportive people they would like to involve in
the FPE program. Some consumers may choose
a relative. Others may identify a friend, employer,
colleague, counselor, or other supportive person.

Set up referral procedures

Agency administrators and family intervention
coordinators must also develop referral procedures.
Modify intake forms to prompt agency staff to
tell consumers who are new to the agency about
the FPE program and elicit their interest in
participating. Also include a section on your
assessment or treatment planning forms that
prompts similar questions so that practitioners
routinely provide information about the
FPE program.

Some agencies also encourage referrals through
the following sources:

n Treatment team meetings;

n Internal or external service providers;

n Community presentations; or

n Consumer self-referrals.

Put your procedures into operation by identifying
and educating referral sources about the FPE
program. Procedures for advertising your FPE
program will depend on your referral approach. For
example, if your FPE program primarily depends
on referrals from treatment team members and
other internal service providers, routinely conduct
agency-wide presentations to develop a basic
understanding of your FPE program.

Consumers do not have to accept that they
have a mental illness to be referred to the FPE
program. FPE practitioners can effectively work
with consumers even if they do not believe that
they have a given diagnosis. Develop a process for
explaining your FPE program to consumers in a
way that helps them make an informed decision
about accepting services.

Review confidentiality policies

Confidentiality policies vary from state to state.
In many states, policies do not specifically discuss
releasing confidential information to family
members of consumers with mental illnesses. As a
result, practitioners may be reluctant to speak with
family members or they may be confused about the
types of information that they may share (Marshall
& Solomon, 2003).

Review your agency’s confidentiality policies.
Find out if consumers must complete a Release
of Information Form to give permission to share
confidential information with their family members.
If so, review your agency’s current forms to see if
they are appropriate for this purpose. For example,
Release of Information Forms created solely for
sharing information between agencies may be
limited to 30, 60, or 90 days. Using these forms for
your FPE program may cause undue burden on FPE
practitioners who would be required to complete
multiple forms for each consumer over the course
of the program. In such cases, consider revising
your forms to meet the needs of the FPE program.
For resources to help you modify your Release of
Information Forms, see The Evidence in this KIT.

Building Your Program 25 Tips for Administrators and Coordinators

Establish staffing criteria

Your policies and procedures should also specify
the staffing criteria for your program. Include clear
and useful job descriptions in your staffing criteria.
For job applicants, a good position description
clarifies whether a particular position matches their
skills and expectations.

Include the following in your job descriptions:

n Task-specific position descriptions;

n Main task categories; and

n Specific duties.

Clear job descriptions allow family intervention
coordinators to effectively supervise new employees
and also allow employees to focus on the basic
elements of their jobs.

When offering FPE in the multifamily group
format, designate two FPE practitioners to facilitate
each group. The recommended size of a FPE
multifamily group is five to eight consumers.

More information is provided above under
Recruiting your staff.

Discuss program organization
and communication

Policies and procedures for your FPE program
should include criteria for how the FPE program
is organized and how practitioners communicate.
To be effective, FPE practitioners must be able to
work both independently and as team members,
especially if they are providing FPE in the
multifamily group format.

As team members, FPE practitioners should
communicate regularly and provide cross-coverage
for consumers. They should also attend weekly
group supervisory meetings that the family
intervention coordinator facilitates. These meetings
give FPE practitioners the opportunity to discuss
and problem-solve consumers’ cases.

FPE practitioners should be part of a
multidisciplinary treatment team. When working
with treatment team members, FPE practitioners
should model evidence-based practice treatment
skills. Your policies should outline clear procedures
for how FPE practitioners will communicate
with multidisciplinary treatment team members.
They should also coordinate services with other
team members to ensure that treatment supports
recovery goals.

Offer Family Psychoeducation in both
individual or group formats

Your policies should specify that ongoing FPE
sessions may be provided either in the single-
family or multifamily group format. The format
that you choose depends on consumer and family
preferences and needs.

In general, single-family formats tend to be used
for the following:

n Consumers and families with strong social
support networks;

n Consumers and families who exhibit unusual
resilience or strong coping skills; or

n Consumers who respond positively to
medications.

Multifamily groups tend to be used for the
following:

n Consumers who are experiencing their first
episode with mental illness;

n Consumers who are not responding well to
medication and treatment;

n Consumers who are experiencing complicating
issues such as other medical illnesses;

n Families experiencing high stress;

n Families who have separated from their relative
with mental illness; and

n Families who have been through divorce.

Tips for Administrators and Coordinators 26 Building Your Program

Participating in the multifamily group format
has other benefits for both consumers and their
families. For example, the social stigma related
to mental illnesses causes many consumers
and families to feel socially isolated. FPE in a
multifamily group format connects consumers and
families to others who have had similar experiences.
It gives them a forum for peer support and mutual
aid by allowing participants to share solutions that
have worked for them. For this reason, whenever
possible, we recommend offering ongoing FPE
services in a multifamily group format.

FPE practitioners commonly work in both
multifamily or single-family group formats. For
example, when multifamily group members are
unable to attend specific group sessions, FPE
practitioners may offer single-family sessions to
accommodate scheduling difficulties.

For information for practitioners about providing
FPE in both individual and group formats, see
Training Frontline Staff in this KIT.

Determine the length of your sessions
and program

In your FPE policies and procedures, outline the
length of FPE sessions and the program. FPE
services are provided in three phases:

n Joining sessions;
n An educational workshop; and
n Ongoing FPE sessions.

During the joining sessions in the first phase, FPE
practitioners meet with each FPE consumer and
their respective family members at least three times
for about 1 hour. You may hold joining sessions with
consumers and their respective family members
together or meet separately with them. (That
means you would conduct six or more sessions
instead of three or more.)

FPE practitioners base their decisions about
offering joining sessions to consumers and family
members jointly or separately on consumer
and family preferences, diagnosis, and illness
characteristics. For information to help FPE
practitioners make these decisions, see Training
Frontline Staff in this KIT.

During the second phase of the FPE program, a
1-day educational workshop is offered. Typically,
the workshop is conducted solely with families—
not with consumers—to give families a chance to
speak freely about their experiences and to interact
with others who are in similar situations.

Some agencies involve consumers in part of the
workshop to ensure that they receive the same
educational information as their families. Others
offer this information to consumers individually
or in a separate consumer forum. Typically, this
workshop is offered only once to participants in
the FPE program. You should offer it within 1 or 2
weeks after joining sessions are completed.

You may offer the last phase of the FPE program—
ongoing FPE sessions—in either the single-family
or multifamily group format. FPE multifamily
groups consist of five to eight consumers and their
respective family members. They meet every 2
weeks for 1½ hours. Two FPE practitioners co-
facilitate the group.

In the single-family format, one FPE practitioner
meets individually with consumers and their
respective family members. Meetings are usually
every 2 weeks for 1 hour. Offer both single-family
and multifamily sessions for 9 months or more.

Building Your Program 27 Tips for Administrators and Coordinators

Ensure stage-wise provision of services

In your policies and procedures specify that
all three phases of the FPE program should be
provided in order. Also, FPE practitioners should
complete the first phases of the FPE program in
full before offering the next.

Coordinating the timing of the phases requires
some planning and organizing. If FPE occurs
in the multifamily group format, the two FPE
practitioners who will facilitate the group divide
the responsibility for conducting joining sessions.
For example, out of eight consumers and their
respective family members, each practitioner
would join with four. Offer the 1-day educational
workshop within 1 to 2 weeks after joining sessions
have been completed.

To achieve the stage-wise provision of services,
set aside time for planning meetings during the
first phase of the program. Begin the planning
process by developing a list of potential consumer
participants. When both FPE practitioners begin
joining sessions simultaneously, it will be easier
to coordinate the timing of the second and third
phases. Include in your policies and procedures
that FPE practitioners should meet weekly during
this time period to ensure that you provide services
in stages.

Adjust practitioners’ caseloads

In the first 3 months of implementing your FPE
program, practitioners are involved in a number of
activities including training activities and planning
meetings. Consequently, initially they will have an
increased workload.

To effectively implement FPE, reduce
practitioners’ caseload until the first two phases
of the FPE program are completed. Once
practitioners have completed their first joining
sessions and 1-day educational workshop and your
family intervention coordinator has developed
procedures to routinely identify and refer
consumers to the FPE program, workload demands
will be substantially decreased. You can restore
caseload size.

Structure your Family
Psychoeducation sessions

Policies and procedures for your FPE program
should also outline the structure of FPE sessions.
Following a prescribed structure helps FPE
practitioners provide effective FPE services.
Specifically, FPE practitioners complete a
prescribed set of tasks for each joining session.
The tasks are outlined in the sample Progress
Notes on the next few pages.

In the second phase of the FPE program, FPE
practitioners offer a 1-day educational workshop
that follows a standardized educational curriculum.
The structure of the workshop is also outlined in
a sample Progress Note on the next few pages.

Ongoing FPE sessions follow a structured approach
shown below:

Multifamily Group Session Agenda

Socialize 15 minutes

Identify current issues—go-around 20 minutes

Select a single problem 5 minutes

Use structured problem solving 45 minutes

Socialize 5 minutes

Total 90 minutes

Tips for Administrators and Coordinators 28 Building Your Program

The structured problem-solving approach is also
outlined in a sample Progress Note on the next
few pages.

In your FPE policies and procedures, encourage
practitioners to follow the suggested structure
during each phase of the FPE program.

Offer other core service components

Your FPE policies should also discuss how to
assertively engage consumers and families.
Engaging consumers and families in FPE starts the
moment that they are referred to the program and
continues throughout the program.

FPE practitioners assertively engage consumers
and family members by phone, by mail, or in
person (in the agency or in the community). To
keep consumers and families engaged in services,
encourage FPE practitioners to routinely reassess
the issues that consumers and families are facing
and offer services to meet their needs.

FPE practitioners also keep consumers and family
engaged in FPE services by routinely offering
educational materials tailored to their own needs.
Policies and procedures should encourage FPE
practitioners to provide educational materials
in several formats (for example, paper, video,
and Web sites).

Document Family Psychoeducation services

Outline the policies and procedures for
documenting FPE services. Instruct FPE
practitioners to complete Progress Notes to
document the following:

n Meeting the goals of each joining session;

n Providing a standardized educational curriculum
to each FPE family participant; and

n Following the structured problem-solving
approach during ongoing FPE services.

For sample Progress Notes tailored to each phase
of the FPE program, see the next pages. For
printable copies, see the CD-ROM for this KIT. We
strongly encourage you to adapt these forms and
incorporate them into your routine paperwork.

Building Your Program 29 Tips for Administrators and Coordinators

/ /

Progress Note Joining Session 1

Consumer’s name: Consumer’s
I.D. number:

Family or other supporter’s name: Relationship
to consumer:

Family or other supporter’s name: Relationship
to consumer:

Date __________________________________
Start time:

Stop time:

Completed by:

Past or present crisis:

Precipitating events:

Early warning signs:

Tips for Administrators and Coordinators 30 Building Your Program

Progress Note Joining Session 1

Family or other

supporter’s experience:

Strengths and helpful

coping skills:

Past unsuccessful strategies

or interventions:

Action steps:

Building Your Program 31 Tips for Administrators and Coordinators

Progress Note Joining Session 2

Consumer’s name: Consumer’s
I.D. number:
Family or other supporter’s name: Relationship
to consumer:
Family or other supporter’s name: Relationship
to consumer:
Date __________________________________
Start time:
Stop time:
Completed by:

Feelings or reactions to illness:

Social support system:

Genogram:

/ /

Tips for Administrators and Coordinators 32 Building Your Program

Progress Note Joining Session 2

Past experiences with the

mental health system:

Educational information shared:

Action steps:

Building Your Program 33 Tips for Administrators and Coordinators

Progress Note Joining Session 3

Consumer’s name: Consumer’s
I.D. number:
Family or other supporter’s name: Relationship
to consumer:
Family or other supporter’s name: Relationship
to consumer:
Date __________________________________
Start time:
Stop time:
Completed by:

Personal strengths (hobbies,

interests, work, school, etc.):

Short-term goals

Long-term goals:

Concerns about participating in

the educational workshop or

multifamily group:

/ /

Building Your Program 35 Tips for Administrators and Coordinators

Progress Note 1-day Educational Workshop

Consumer’s name: Consumer’s
I.D. number:
Family or other supporter’s name: Relationship
to consumer:
Family or other supporter’s name: Relationship
to consumer:
Date __________________________________
Start time:
Stop time:
Completed by:

Was the consumer present for

the workshop?
 Yes

No
In part
Attended a separate consumer forum
Received individual education

Was the family member present for

the workshop?
 Yes

No
In part
Provided individual education

Which of the following topics

were presented?
 Psychobiology of the specific mental illness including basics of brain

function and dysfunction and the potential causes of the mental illness

Diagnosis including symptoms and prognosis

Treatment and rehabilitation including an overview of the treatment options
and how they promote effective coping and illness management strategies

Impact of mental illness on the family including how mental illnesses affect
families as a whole

Relapse prevention including prodromal signs and symptoms and the role of
stress in the precipitating episodes

Family guidelines or recommended responses to help families maintain a
home environment that promotes relapse prevention

In which of the following

formats were educational

materials presented?

 Handouts
Slides
Video
Web Sites
Other _____________________________________

/ /

Building Your Program 37 Tips for Administrators and Coordinators

Multifamily Group Problem Solving Worksheet

Consumer’s name: Consumer’s
I.D. number:
Family or other supporter’s name: Relationship
to consumer:
Family or other supporter’s name: Relationship
to consumer:
Date __________________________________
Start time:
Stop time:
Completed by:

Step 1: Define the problem

Step 2: Generate solutions

/ /

Tips for Administrators and Coordinators 38 Building Your Program

Multifamily Group Problem Solving Worksheet

Step 3: Discuss advantages

and disadvantages

Possible solution Advantages Disadvantages

Step 4: Choose the best solution

Step 5: Form an action plan

Step 6: Review the action plan

Building Your Program 39 Tips for Administrators and Coordinators

 

How Administrators and Family
Intervention Coordinators Can Help
Provide Recovery-Oriented Services

n Clearly explain consumer rights in FPE
policies and procedures.

n Offer training on recovery principles and
consumer rights to practitioners, consumers,
and families.

n Hold community forums using the
multimedia tools in this KIT.

n Involve consumers in local advisory groups.

Describe how to maintain
consumer records

In the policies and procedures for your FPE
program, describe how you will maintain
consumers’ records. You must keep records for
each consumer and safeguard them against loss,
tampering, and unauthorized use. The records
should be consistent with requirements of
organizations to whom you bill (e.g., the Centers
for Medicaid and Medicare Services) or that
accredit your agency (e.g., the Joint Commission
on Accreditation of Rehabilitation Facilities, etc.).

If you are setting up a new recordkeeping
system, you will need materials to create records
(for example, binders and forms) and to store
them appropriately. You also need written
policies and procedures for documenting and
maintaining records.

Make sure that FPE practitioners are familiar with
your policies and procedures for documenting and
maintaining records. Supervise them in completing
the required documentation and monitor that
records are properly stored and protected.

Discuss how to ensure
consumers’ rights

In the policies and procedures for your FPE
program, discuss how you will ensure that
consumers’ rights are upheld. FPE practitioners
should do the following:

n Be aware of the state and federal consumer
rights requirements;

n Inform consumers of their rights in a meaningful
way; and

n Help consumers exercise their rights.

Also, your policies and procedures should reflect
the model’s recovery orientation. Traditional
services were developed with a biomedical
approach to mental health treatment; they focus
on reducing symptoms and preventing relapse. In
contrast, the evidence-based model is based on the
concept of recovery. In the recovery framework,
the expectation is that consumers can have lives in
which mental illnesses are not the driving factors.
Recovery means more than maintaining people
with mental illnesses in the community. Recovery-
oriented services encourage consumers to define
and fulfill their personal goals.

FPE practitioners must believe in and be true
to the recovery principles in the evidence-based
model. Be careful not to replicate those elements
of traditional services that simply emphasize
containing symptoms and complying with
medication.

The value of consumer choice in service delivery
and the importance of consumer perceptions
must be infused in how you provide FPE. Most
practitioners have never examined their own
attitudes and behaviors about consumer recovery
and uncritically accept many clinical traditions
without paying attention to how disempowering
these practices are for consumers.

Tips for Administrators and Coordinators 40 Building Your Program

In recovery-based services, establishing a
trusting relationship is critical. Interactions with
consumers should be based on mutuality and
respect. Challenge FPE practitioners to listen to,
understand, and respect consumers’ perspectives
and take into account consumers’ reasons
for noncompliance.

FPE practitioners should also focus on consumer-
defined needs and preferences and accept
consumer choice in service delivery. Providing
services with a recovery orientation means that you
support and empower consumers to achieve their
individual goals.

Develop procedures to evaluate
program and staff performance

When it is properly implemented, FPE is
associated with a variety of positive consumer
and family outcomes. Evaluating the performance
of your FPE program will help you provide
high-quality services and assure stakeholders of
your program’s effective performance. Develop
procedures to evaluate your program early using
the guidelines in Evaluating Your Program in
this KIT. Also, develop procedures for how you
will supervise and evaluate your FPE team. To
a large extent, clinical supervision is the process
that will determine whether FPE staff understand
and are consistently applying the evidence-based
practices for family psychoeducation or whether
further leadership, training, and accountablility
are required to meet this goal.

Family intervention coordinators should provide
weekly group supervision to FPE practitioners.
Group supervision should review all consumers
involved in the FPE program and problem-
solve ways to help them better meet their
individual goals.

Family intervention coordinators also should
provide individual, side-by-side supervision
to achieve the following goals:

n Assess performance;

n Give feedback; and

n Model interventions.

Family intervention coordinators may schedule
regular meetings with FPE practitioners to review
specific cases. They should be regularly available
to consult with FPE practitioners, as needed.

Some aspects of the FPE practitioner’s job are
hard to understand without seeing them done
by an experienced FPE practitioner. Once family
intervention coordinators thoroughly understand
the evidence-based model, they should model
aspects of the job—such as engagement or
educational techniques—and directly coach
them in their work. For training tools and
recommendations, see Training Frontline Staff
in this KIT.

If the FPE program is working with a consultant,
the family intervention coordinator should involve
the consultant in group supervision, treatment team
meetings, and FPE multifamily group sessions.
If the attendance of an outsider disrupts the
group process, consider periodically videotaping
sessions for purposes of supervision. Many new
FPE programs have found that feedback from
an external consultant is a crucial component
for improving staff performance and the quality
of their program as a whole.

Tips for Administrators and Coordinators 42 Building Your Program

Hire an external consultant and trainer

Establishing the initial processes that must be
in place to provide quality services requires great
attention to detail. Consequently, during the first 1
to 2 years after forming a new FPE program, many
agencies have found it helpful to work with an
experienced external consultant and trainer.

Consultants and family intervention coordinators
often work together to ensure that the FPE
program is structured appropriately. They integrate
evidence-based practice principles into the agency’s
policies and tailor procedures to meet local needs.

Once the FPE program has been launched, it
is important that you not allow FPE practitioners
to revert to older and more familiar ways of doing
things. External consultants and trainers who
are experienced in running FPE programs can
provide ongoing technical assistance, side-by-
side supervision, and periodic booster training
sessions. This type of assistance, along with ongoing
evaluation of fidelity and outcomes, has been found
to be critical in maintaining adherence to the
evidence-based practices.

Select a location for your Family
Psychoeducation program

You can conduct FPE sessions in almost any
location that is convenient for practitioners,
consumers, and families. For example, you could
conduct joining sessions in the following locations:

n Your mental health agency;

n Consumers’ homes; or

n Consumers’ family members’ home.

When selecting a location for the 1-day educational
workshop and multifamily groups, consider
the following:

n The number of participants;

n Type of multimedia you plan to use;

n Comfort and convenience of the location; and

n The ability to serve refreshments.

Regardless of the location, FPE practitioners
should strive to create an environment that is quiet,
free of unnecessary distractions, and conducive to
sharing and learning from one another.

Building Your Program 43 Tips for Administrators and Coordinators

Review your program budget
and revenue sources

It is important that you understand the budget
for your FPE program and revenue sources so
that you can actively participate in the budgeting
process, make informed management decisions,
and understand where collateral revenue sources
are most needed.

What are the costs?

The initial implementation costs are about $250
per practitioner for recruitment, preparation, and
associated costs for training. Other agency costs
include agency administration time, planning
meetings, supervision, consultation, and costs
associated with reducing practitioner caseloads
during the first two phases of the FPE program.

Ongoing FPE sessions in the multifamily group
format require about 1 hour of staff effort per
month for each consumer in addition to the time
spent in group. Based on East Coast salary levels,
when using a master’s-level practitioner, the costs
of providing ongoing FPE session in a multifamily
group format is about $350 per year, per consumer
in staff time. Single-family format is roughly twice
the cost per consumer.

The FPE budget should also include funds to cover
the costs of refreshments for the 1-day educational
workshop and multifamily groups, as well as
multimedia educational materials.

What are the revenue sources?

Financing mechanisms for FPE programs vary
from state to state. Typically, FPE programs are
funded by a combination of state mental health
dollars, Medicaid, and other insurers.

In some mental health systems, programs receive a
fixed rate for each consumer who receives services.
In other systems, programs are only reimbursed
based on the specific services provided. In that
case, you should be familiar with how services must
be tracked to capture billing from various funding
streams. You will also need to know the billing
process and billing codes.

Financial barriers can slow implementation.
Be aware that over time the mission and activities
of programs can become defined by the funding
that supports them. Know the principles of the
evidence-based model and be vigilant that funding
opportunities support the model rather than shape
and corrupt it. For useful ideas and strategies,
consult with agencies and system administrators
who have been successful in this area.

In summary, building an effective, well-functioning
FPE program is a developmental process.
We encourage you to periodically revisit the
information in this KIT throughout the first year
after you start your new program. We believe that
these materials will take on a new meaning as the
process of implementing an FPE program evolves.

26172.0709.7765020404

HHS Publication No. SMA-09-4422
Printed 2009

Cover
• Title Page

Acknowledgments
Building Your Program
What’s in Building Your Program
What Is Family Psychoeducation?
The phases of Family Psychoeducation
Practice principles
How we know that Family Psychoeducation is effective
Who benefits most from Family Psychoeducation?
Where should Family Psychoeducation be provided?
Is it cost effective?
Tips for Mental Health Authorities
Why should you be interested in Family Psychoeducation?
How can mental health authorities support Family Psychoeducation?

• Tips for Agency Administrators and Family Intervention Coordinators

Recruit your staff
Build support for your program
Develop effective policies and procedures
Develop a training plan
Select a location for your Family Psychoeducation program
Review your program budget and revenue sources

Training
Frontline

Staff

Family

Psychoeducation

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

http://www.samhsa.gov

Family
Psychoeducation

Training
Frontline Staff

U.S. Department of Health and Huma

n

Services

Substance Abuse and Mental Health Services Administratio

n

Center for Mental Health Services

Acknowledgments

This document was prepared for the Substance Abuse and Mental Health Services Administration
(SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number
280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Department
of Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served as
SAMHSA Government Project Officers.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors and
do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services
(CMHS), SAMHSA, or HHS.

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced or
copied without permission from SAMHSA. Citation of the source is appreciated. However,
this publication may not be reproduced or distributed for a fee without the specific, written
authorization from the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, please
call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English
and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Family Psychoeducation: Training
Frontline Staff. HHS Pub. No. SMA-09-4422, Rockville, MD: Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration, U.S. Department of Health and
Human Services, 2009.

Originating Office

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
Rockville, MD 20857

HHS Publication No. SMA-09-4422
Printed 2009

http://www.samhsa.gov/shin

Family
Psychoeducation

Training Frontline Staff

This five-module workbook will help family intervention coordinators
teach practitioners about the principles, processes, and skills necessary
to deliver effective Family Psychoeducation services. The workbook
includes the following topics:

n  Basic elements and practice principles;

n  The core processes of Family Psychoeducation;

n  Joining sessions and educational workshops;

n  Ongoing Family Psychoeducation sessions; and

n  Problem solutions from actual practice.

For references see the booklet, The Evidence.

This KIT is part of a series of Evidence-Based Practices KITs created
by the Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration, U.S. Department of Health
and Human Services.

This booklet is part of the Family Psychoeducation KIT that includes
a DVD, CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Staff

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP

What’s in Training Frontline Staff

How Family Intervention Coordinators
Should Use This Workbook . . . . . . . . . . . . . . . . . . . .A
Prepare program-specific information . . . . . . . . . . . . . . . . . B
Prepare agency-specific information . . . . . . . . . . . . . . . . . . C
Visit an existing team . . . . . . . . . . . . . . . . . . . . . . . . . . . . C
Arrange for didactic training . . . . . . . . . . . . . . . . . . . . . . . D
Recruit a consultant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D
Cross-train . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D

Module 1: Basic Elements and Practice Principles . . . . . 1
What is Family Psychoeducation? . . . . . . . . . . . . . . . . . . . . 1
The phases of Family Psychoeducation . . . . . . . . . . . . . . . . 2
Practice principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The family experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Core values in Family Psychoeducation . . . . . . . . . . . . . . . . 4
Program standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we know that Family Psychoeducation is effective. . . . . 6
Adapting the evidence-based model . . . . . . . . . . . . . . . . . . 7
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Exercise: Explore the Benefits of Family Psychoeducation . . . 9
Exercise: Examine Program Standards . . . . . . . . . . . . . . . . 11

Family
Psychoeducation

Module 2: The Core Processes
of Family Psychoeducation . . . . . . . . . . . . . . . . . . . . 1
Identify consumers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Introduce the program . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Conduct joining sessions . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Conduct the educational workshop . . . . . . . . . . . . . . . . . . . 4
Offer ongoing Family Psychoeducation services . . . . . . . . . . 4
Engage consumers and families continuously . . . . . . . . . . . 6
Complete Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Participate in supervision . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Exercise: Identify Consumers and Families . . . . . . . . . . . . . . 9
Exercise: Introduce Your Program . . . . . . . . . . . . . . . . . . . 11

Module 3: Joining Sessions
and Educational Workshops . . . . . . . . . . . . . . . . . . . 1
Joining sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Educational workshops . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Exercise: Review Progress Notes for Joining Sessions
and Educational Workshops . . . . . . . . . . . . . . . . . . . . . . . 13
Exercise: Practice What You’ve Learned About
Joining Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Module 4: Ongoing Family Psychoeducation Sessions

. . 1
Conduct ongoing Family Psychoeducation sessions . . . . . . . 1
Structure of multifamily groups . . . . . . . . . . . . . . . . . . . . . 2
Overview of the first session . . . . . . . . . . . . . . . . . . . . . . . . 2
Overview of the second session . . . . . . . . . . . . . . . . . . . . . 5
Ongoing multigroup sessions . . . . . . . . . . . . . . . . . . . . . . . 6
Exercise: Practice What You’ve Learned
About Multifamily Groups . . . . . . . . . . . . . . . . . . . . . . . . 13
Exercise: Review the Progress Note for Ongoing Family
Psychoeducation Sessions . . . . . . . . . . . . . . . . . . . . . . . . . 15

Module 5: Problem Solutions from Actual Practice

. . . . 1
Overview of the module . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Employment issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Medication issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Exercise: Practice What You’ve Learned About
Problem Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Training Frontline Staff

A

Training Frontline Staff

How Family Intervention Coordinators
Should Use This Workbook

Training Frontline Staff introduces
practitioners to the basic principles and
skills they need to deliver effective Family
Psychoeducation (FPE) services. Use this
workbook with the Practice Demonstration
Video and the English or Spanish
Introductory Video on the DVD in
this KIT.

Because being part of a team and learning
how to process information together are
essential parts of FPE, we recommend that
you conduct group training sessions rather
than simply give FPE practitioners the
workbook to read on their own.

To make the content easy to manage, we
divided the training into five modules.

The Five Family
Psychoeducation Modules
in Training Frontline Staff

1 Basics Elements and Practice
Principles.

2 The Core Processes of Family
Psychoeducation

3 Joining Sessions and Educational
Workshops

4 Ongoing Family Psychoeducation
Sessions

5 Problem Solutions from Actual
Practice

B Training Frontline Staff

How to Complete this Five-Session Training

 

n  Arrange for FPE practitioners to meet at least once a week for 5 weeks. You will cover up to one module
each week.

n  In this workbook, on the page before each module, you’ll find Notes to the family intervention
coordinator. Review the notes to prepare for the training.

n  Copy and distribute the module’s reading materials so that practitioners can read them before
the training session. You’ll find this booklet on the KIT’s CD-ROM.

n  Copy the exercises for each module so that you can complete them during each training
session. You’ll find the exercises in this booklet on the KIT’s CD-ROM.

n  For each session, ask a different group member to facilitate.

n  Begin each training session by showing the corresponding segments
of the Practice Demonstration Video.

n  Discuss the information on the video and in the workbook.

n  Complete the suggested exercises for that module.

The ultimate purpose of this workbook is to have
practitioners understand the principles behind the
FPE model, how FPE is delivered, and the skills
necessary to provide effective services. We have
found that practitioners prefer to read one module
at a time and then discuss that module with
colleagues as a group. Working through these
modules as a group creates an opportunity to
discuss and master the core values and teaching
principles that are essential to effective FPE
practice.

Prepare program-specific
information

In addition to providing the materials in this
workbook, you should prepare to give FPE
practitioners information about FPE policies
and procedures. These include the following:

n Procedures for identifying consumers
for the program;

n  Conditions under which consumers will
be discharged from the program;

n Procedures for completing FPE Progress Notes;

n Criteria for assessing the program’s fidelity
to the FPE model; and

n Outcomes that will be monitored.

For sample forms, see Building Your Program
and Evaluating Your Program in this KIT.

Training Frontline Staff C

Prepare agency-specific
information

You should also develop a plan to train practitioners
about other policies and procedures that may be
relevant to the agency in which the FPE program
operates. These might include the following:

n Consumers’ rights: Practitioners should be
aware of the state and federal consumer rights
requirements.

n Billing procedures: Practitioners must know
how to document and bill for FPE services.

n Safety: Many agencies with existing community-
based programs have materials about safety.
If training in this area is not already available,
plan for training in de-escalation techniques.

n Mandated reporting: Practitioners must know
how to report suspected abuse and neglect. They
also must know what to do if they find out about
other illegal activity and threats of harm to self
or others.

n Other policies and procedures: Consult your
agency’s human resources office to learn of other
program, agency, or state policies that the staff
should know.

Visit an existing team

After your FPE team completes this workbook,
we suggest that new practitioners observe an
experienced, high-fidelity FPE program. If you
are familiar with these materials before your visit,
your visit will be more productive. Rather than
using time to explain the basics, the host program
will be able to show the new FPE practitioners
how to apply the basics in a real-world setting.

Arrange for didactic training

After using this workbook and visiting an
experienced FPE program, FPE practitioners will
be ready for a trainer who will help them practice
what they have seen and read. Some family
intervention coordinators choose to hire an
external trainer to help their team practice FPE
principles, processes, and skills. The initial training
should take 2 to 3 days.

Recruit a consultant

Once FPE practitioners begin working with
consumers, you—along with the agency director—
are responsible for ensuring that they follow the
evidence-based model. This task can be challenging.

You must facilitate a staff development process,
apply what you have just learned about FPE in your
own clinical work with consumers, and, at the same
time, ensure through clinical supervision that FPE
practitioners follow the model.

It is easy to stray from the evidence-based model
and do something similar to but not quite the
same as FPE. Sometimes this happens because
practitioners believe they are diligently following
the FPE model, but they miss some of the more
subtle aspects of it. In other cases, FPE services
start well, but, as more consumers are admitted
to the program and pressure mounts, practitioners
revert to older, more familiar ways of working.

To ensure that your team follows the FPE model,
work with an experienced consultant throughout
the first year of operation. A consultant can provide
ongoing telephone and in-person support to help
you with your challenging leadership role.

D Training Frontline Staff

Cross-train

It is important that staff throughout your agency
develop a basic understanding of FPE. Cross-
training will ensure that other staff members
support the work that the FPE team undertakes.

As discussed in Building Your Program, we also
recommend that you train members of your FPE
advisory group. The more information that advisory
group members have about FPE, the better they
will be able to support the program and its mission.

Training is also an opportunity for FPE
practitioners and advisory group members to
become familiar with one another. Make sure that
the advisory group members and FPE practitioners
introduce themselves and that they are familiar
with each other’s roles.

To help you conduct your training, we include these
multimedia materials in the FPE KIT:

n Introductory PowerPoint presentation;

n Sample brochure; and

n Introductory Video.

Once trained, you or your staff will be able to
use these materials to present routine, inservice
seminars to ensure that all staff members within
the agency and advisory group members are
familiar with the FPE program.

For more information

The information in this workbook provides a
detailed overview of the FPE model. For more
information, see the following resources:

Anderson, C., Hogarty, G., & Reiss, D. (1986).
Schizophrenia and the family. New York:
Guilford Press.

McFarlane, W. R., (Ed.). (2002). Multifamily
groups in the treatment of severe psychiatric
disorders. New York: Guilford.

We consistently found that agencies used these
additional resources with this KIT to develop
and manage their FPE programs. For this reason,
we recommend the first resource to those
implementing FPE in a single-family format and
the second resource to those implementing FPE
in the multifamily group format. For additional
resources, see The Evidence in this KIT.

Basic Elements and Practice Principles E

Module 1

Module 1

Basics Elements and

Practice Principles

Notes to the family intervention coordinator

Prepare for Module 1:

n Make copies of Module 1. Your copy
is in this workbook; print additional
copies from the KIT’s CD-ROM.

n Distribute the material to the FPE practitioners
who will participate in your group session. Ask
them to read it before meeting as a group.

n  Make copies of these exercises:

o Explore the Benefits of Family
Psychoeducation

o Examine Program Standards

n Make copies of these documents
found in Evaluating Your Program
in this KIT:

o The Family Psychoeducation Fidelity Scale

o General Organizational Index

o Outcome measures that your agency
will monitor (if available)

Do not distribute them until your group training .

Conduct your first session:

n When you convene your group, view
the Introductory Video. Discuss the
video and the content of Module 1.

n Distribute the following:

o The Family Psychoeducation Fidelity Scale
o General Organizational Index

o Outcome measures that your agency will
monitor (if available)

o The exercises for this module

n Review the distributed materials and complete
the exercises as a group.

Facilitating the dialogue: One of the
roles of a family intervention coordinator
is to facilitate the dialogue during group
training sessions. Some people have difficulty
speaking in a group, perhaps because they
are timid or soft-spoken. Others may feel
professionally intimidated by those with more
experience or higher degrees. Conversely,
some practitioners will be self-confident and
outspoken and will need to learn to listen
openly to what others have to say.

As you work together on each module,
encourage those who are more withdrawn
to express their views and make sure that
the more vocal people give others a chance
to speak. Group training also gives you the
opportunity to assess the anxiety that FPE
practitioners may feel about providing FPE
services. Use your group training time to
explore and address issues openly.

Basic Elements and Practice Principles 1 Module 1

Training Frontline Staff

Module 1: Basic Elements and Practice Principals

Module 1 explains the basic elements of Family Psychoeducation, including the
practice principles of the model. This module orients practitioners to how consumers
and families may benefit from the evidence-based practice.

What is Family
Psychoeducation?

Family Psychoeducation (FPE) is an
approach for partnering with consumers
and families to treat serious mental
illnesses. FPE practitioners develop
a working alliance with consumers
and families.

The term psychoeducation can be
misleading. While FPE includes many
working elements, it is not family therapy.
Instead, it is nearly the opposite. In family
therapy, the family itself is the object of
treatment. But in the FPE approach, the
illness is the object of treatment, not the

family. The goal is that practitioners,
consumers, and families work together
to support recovery.

Serious mental illnesses such as
schizophrenia, bipolar disorder, and major
depression are widely accepted in the
medical field as illnesses with well-
established symptoms and treatment.
As with other disorders such as diabetes
or hypertension, it is both honest and useful
to give people practical information about
their mental illnesses, how common they
are, and how they can manage them.

Many consumers and families report that
this information is helpful because it lets
them know that they are not alone and it

Module 1 2 Basic Elements and Practice Principles

empowers them to participate fully in the recovery
process. Similarly, research shows that consumer
outcomes improve if families receive information
and support (Dixon et al., 2001). For this reason,
a number of family psychoeducation programs have
been developed over the past two decades.

Models differ in their format (whether they use
multifamily or single-family format); duration of
treatment; consumer participation; and location.
Research shows that the critical ingredients of
effective FPE include the following (Dixon et
al., 2001):

n Education about serious mental illnesses;

n Information resources, especially during periods
of crises;

n Skills training and ongoing guidance about
managing mental illnesses;

n Problem-solving; and

n Social and emotional support.

The phases of Family
Psychoeducation

FPE services are provided in three phases:

n Joining sessions;

n An educational workshop; and

n Ongoing FPE sessions.

Joining sessions

Initially, FPE practitioners meet with consumers
and their respective family members in introductory
meetings called joining sessions. The purpose of
these sessions is to learn about their experiences
with mental illnesses, their strengths and resources,
and their goals for treatment.

FPE practitioners engage consumers and families
in a working alliance by showing respect, building
trust, and offering concrete help. This working

alliance is the foundation of FPE services.
Joining sessions are considered the first phase
of the FPE program.

Educational workshop

In the second phase of the FPE program, FPE
practitioners offer a 1-day educational workshop.
The workshop is based on a standardized
educational curriculum to meet the distinct
educational needs of family members.

FPE practitioners also respond to the individual
needs of consumers and families throughout the
FPE program by providing information and
resources. To keep consumers and families engaged
in the FPE program, it is important to tailor
education to meet consumer and family needs,
especially in times of crisis.

Ongoing Family Psychoeducation sessions

After completing the joining sessions and 1-day
workshop, FPE practitioners ask consumers
and families to attend ongoing FPE sessions.
When possible, they offer ongoing FPE sessions
in a multifamily group format. Consumers and
families who attend multifamily groups benefit
by connecting with others who have similar
experiences. The peer support and mutual
aid provided in the group builds social support
networks for consumers and families who are
often socially isolated.

Ongoing FPE sessions focus on current issues that
consumers and families face, and address them
through a structured problem-solving approach.
This approach helps consumers and families make
gains in working toward consumers’ personal
recovery goals.

FPE is not a short-term intervention. Studies show
that offering fewer than 10 sessions does not
produce the same positive outcomes (Cuijpers,
1999). We currently recommend providing FPE
for 9 months or more.

Basic Elements and Practice Principles 3 Module 1

In summary, FPE practitioners provide information
about mental illnesses, and help consumers
and families enhance their problem-solving,
communication, and coping skills. When provided
in the multifamily group format, ongoing FPE
sessions also help consumers and families develop
social supports.

Practice principles

FPE is based on a core set of practice principles.
These principles form the foundation of the
evidence-based practice and guide practitioners
in delivering effective FPE services.

Practice Principles

Principle 1:
Consumers define
who family is.

In FPE, the term family includes anyone consumers identify as being supportive in the
recovery process. For FPE to work, consumers must identify supportive people they would
like to involve in the FPE program. Some consumers may choose a relative. Others may
identify a friend, employer, colleague, counselor, or other supportive person.

Principle 2:
The practitioner-
consumer-family
alliance is essential.

Consumers and families have often responded to serious mental illnesses with great resolve
and resilience. FPE recognizes consumer and family strengths, experience, and expertise in
living with serious mental illnesses.

FPE is based on a consumer-family-practitioner alliance. When forming alliances with
consumers and families, FPE practitioners emphasize that consumers and families are
not to blame for serious mental illnesses. Blaming consumers or families is not constructive
or helpful and should be avoided. FPE practitioners partner with consumers and families
to better understand consumers and support their personal recovery goals.

Principle 3:
Education and
resources help families
support consumers’
personal recovery goals.

Consumers benefit when family members are educated about mental illnesses. Educated
families are better able to identify symptoms, recognize warning signs of relapse, support
treatment goals, and promote recovery. Provide information resources to consumers and
families, especially during times of acute psychiatric episodes or crisis.

Principle 4:
Consumers and families
who receive ongoing
guidance and skills
training are better able
to manage mental
illnesses.

Consumers and families experience stress in many forms in response to mental illnesses.
Practical issues such as obtaining services and managing symptoms daily are stressors.
Learning techniques to reduce stress and improve communication and coping skills
can strengthen family relationships and promote recovery. Learning how to recognize
precipitating factors and prodromal symptoms can help prevent relapses. For more
information, see Training Frontline Staff in this KIT.

Principle 5:
Problem-solving helps
consumers and families
define and address
current issues.

Using a structured problem-solving approach helps consumers and families break
complicated issues into small, manageable steps that they may more easily address.
This approach helps consumers take steps toward achieving their personal recovery goals.

Principle 6:
Social and emotional
support validates
experiences and
facilitates problem-
solving.

FPE allows consumers and families to share their experiences and feelings. Social and
emotional support lets consumers and families know that they are not alone. Participants in
FPE often find relief when they openly discuss and problem-solve the issues that they face.

Module 1 4 Basic Elements and Practice Principles

The family experience

Mental illnesses bring about such significant
changes in people’s lives that many families think
in terms of how life was before and after the onset
of the illness. Families often provide emotional and
instrumental support, case management functions,
financial assistance, advocacy, and housing to
relatives with mental illnesses. Doing so can be
rewarding, but also imposes considerable stress.

Family members often find that they lack access to
needed resources and information. Stressors range
from practical problems such as paying medical
bills and obtaining services to issues related to the
symptoms of mental illnesses.

Family members also must cope with their own
emotional responses to having a relative with
mental illnesses. Emotional responses vary from
optimism and hope to denial, guilt, and grief
(Tessler & Gamache, 2000; Hatfield & Lefley,
1987). These feelings may interfere with their
capacity to support and help their relative in
the recovery process.

In addition, consumers and families may face
stigma while coping with serious mental illnesses.
They may find that friends and relatives begin
to avoid them. They may isolate themselves from
natural support networks if they perceive that
others cannot relate to their experiences.
Stigmatization and isolation can lead people to
feel exasperated, abandoned, and demoralized.

Stress, isolation, and stigma can cause tension and
disagreements between consumers and families.
Disagreements can be destabilizing or, at least, can
prevent rehabilitation if they are left unresolved.
Therefore, addressing these issues not only helps
to improve the overall functioning of the family but
also promotes recovery.

FPE addresses these issues by focusing on
consumer and family strengths. Consumers and
families often show great resolve and resilience

when faced with crises related to mental illnesses.
They demonstrate more adaptive coping when
they feel affirmed, respected, and valued for the
information and skills that they possess. For this
reason, FPE sees families as partners and asks
them to share their resources and expertise to
help consumers achieve their recovery goals.

Core values in Family
Psychoeducation

FPE is based on several core values that permeate
the relationship among consumers, families, and
practitioners. These values include the following:

n Building hope;

n Recognizing consumers and families as experts
in their own experience of mental illnesses;

n Emphasizing personal choice;

n Establishing a collaborative partnership; and

n Demonstrating respect.

Build hope

The long-term course of mental illnesses cannot
be predicted, and no one can predict anyone’s
future. However, studies suggest that consumers
and families who actively participate in their
treatment and who develop effective coping skills
have the most favorable course and outcome,
including a better quality of life (Mueser et al.,
2002). The ability to influence your own destiny is
the basis for hope and optimism about the future.

FPE practitioners convey hope and optimism to
consumers and their families. In providing FPE,
practitioners present information and skills as being
potentially useful tools that consumers can use
in pursuing their goals. Informed and involved
families will feel more empowered to support
their relatives’ recovery goals. FPE practitioners
keep an attitude of hope and optimism, even
when consumers and families may be pessimistic.

Basic Elements and Practice Principles 5 Module 1

Recognize consumers and families
as experts

While FPE practitioners have professional expertise
about information and skills for managing and
recovering from mental illnesses, consumers
and families have experience in living with mental
illnesses. Consumers and families know which
strategies have worked in the past for them and
which have not.

FPE practitioners encourage consumers and
families to share their unique experiences with
mental illnesses and response to treatment. By
paying close attention to consumers’ and families’
expertise, you can more effectively help consumers
progress toward their personal goals.

Emphasize personal choice

The overriding goal of FPE is to support consumers
in their personal recovery process. The ability and
right of consumers to make their own decisions is
paramount, even when consumers’ decisions differ
from the recommendations of their family and
practitioners. Certain rare exceptions to this
principle do exist, for example, when legal
constraints such as an involuntary hospitalization
protect consumers from themselves or others.

In general, avoid pressuring consumers to make
certain treatment decisions and encourage families
to do the same. Instead, accept consumers’
decisions and work with them to evaluate the
consequences in terms of their personal goals.

Keeping the emphasis on consumers’ personal
choice is key to establishing and maintaining a
strong alliance with both consumers and families.
FPE practitioners model how respecting consumer
choices, despite disagreements, builds a trusting
relationship that promotes positive change.

Establish a collaborative partnership

While FPE practitioners serve a variety of roles,
they are primarily collaborators. The collaborative
spirit of FPE reflects the fact that consumers,
families, and practitioners work side by side in
a nonhierarchical relationship.

FPE practitioners establish a working alliance with
consumers and families. Together, they learn how
to cope with the unique characteristics of
consumers’ mental illnesses and make progress
toward their personal recovery goals.

Demonstrate respect

Respect is a key ingredient for successfully
collaborating in FPE. FPE practitioners respect
consumers and families as human beings, capable
decisionmakers, and partners in the treatment
process. FPE practitioners accept that consumers
and families may differ in their personal values
and opinions. They respect consumers’ and
families’ right to their own values and opinions.
For example, consumers may disagree that they
have a particular mental illness or that they have
any mental illness at all.

Rather than actively trying to persuade consumers
that they have a specific disorder, FPE practitioners
respect their beliefs while searching for common
ground as a basis for collaboration. Such common
ground could include the following:

n Symptoms and distress that consumers
experience (perhaps even conceptualized
generally as stress, anxiety, or nerve problems);

n Desire to avoid hospitalization;

n Difficulties with independent living; or

n Specific goals they would like to accomplish.

By seeking common ground, FPE practitioners
demonstrate respect for consumers’ beliefs and
their right to make informed decisions based on
their values and beliefs.

Module 1 6 Basic Elements and Practice Principles

Program standards

One of the unique features of FPE is that the
important characteristics of this evidence-based
model have been translated into program standards
to help programs replicate effective services.
An instrument called the FPE Fidelity Scale
summarizes these characteristics and is available
to help quality assurance teams assess how closely
their program follows the evidence-based model
(See Evaluating Your Program in this KIT). Your
family intervention coordinator will give this scale
to you to review and discuss during training.

 

Basic Characteristics of Family
Psychoeducation

n Family intervention coordinator

n Session frequency

n Long-term FPE

n Quality of consumer-family-practitioner
alliance

n Detailed family reaction

n Precipitating factors

n Prodromal signs and symptoms

n Coping strategies

n

Educational curriculum

n

Multimedia education

n Structured group sessions

n Structured problem-solving

n Stage-wise provision of services

n Assertive engagement and outreach

How we know that Family
Psychoeducation is effective

FPE is based on research that shows that families
and consumers who participated in the components
of the evidence-based model experienced 20 to 50
percent fewer relapses and rehospitalizations than
those who received standard individual services
over 2 years (Penn & Mueser, 1996; Dixon &
Lehman, 1995; Lam, Kneipers, & Leff, 1993;
Falloon et al., 1999). Those at the higher end of
this range participated for more than 3 months.

Studies also show that FPE improved family well-
being (Dixon et al., 2001; McFarlane et al., 2003).
Families reported greater knowledge of serious
mental illnesses; a decrease in feeling confused,
stressed, and isolated; and reduced medical illness
and medical care utilization (Dyck, Hendryx, Short,
Voss, & McFarlane,,2002).

FPE has been found to increase consumers’
participation in vocational rehabilitation programs
(Falloon et al., 1985). Studies have shown
employment rate gains of two to four times baseline
levels, when combined with the evidence-based
practice, Supported Employment (McFarlane et
al., 1996; McFarlane et al., 1995; McFarlane et
al., 2000).

Based on this significant evidence, treatment
guidelines recommend involving families in the
treatment process by offering the critical
ingredients outlined in this evidence-based model
(Lehman & Steinwachs, 1998; American Psychiatric
Association, 1997; Weiden, Scheifler, McEvoy,
Allen, & Ross, 1999).

Basic Elements and Practice Principles 7 Module 1

Adapting the evidence-based
model

Research has shown the greatest amount of
benefits rom FPE for families and consumers
with schizophrenic disorders (Dixon et al., 2001).
For this reason, we recommend that new
practitioners first provide FPE services to
consumers with these disorders.

Once practitioners have learned this approach by
working with people with schizophrenia, they find
it relatively easy to modify it for other disorders.
Studies show that FPE may be effectively adapted
and used for the following disorders:

n Bipolar disorder (Clarkin, Carpenter, Hull,
Wilner, & Glick, 1998; Miklowitz & Goldstein,
1997; Moltz, 1993; Parikh et al., 1997; Miklowitz
et al., 2000; Simoneau, Miklowitz, Richards,
Saleem, & George, 1999);

n Major depression (Simoneau et al., 1999;
Emanuels-Zuurveen & Emmelkamp, 1997;
Leff et al., 2000);

n Obsessive-compulsive disorder (Van Noppen,
1999); and

n Borderline personality disorder (Gunderson,
Berkowitz, & Ruizsancho, 1997).

This model also has been adapted and used
effectively in a variety of countries and cultures.
For more information about diagnosis-specific
or cultural adaptations of this model, see The
Evidence in this KIT.

Summary

This module reviewed the basic elements and core
values of FPE. This evidence-based practice is
based on a core set of practice principles, which
have been translated into program standards that
agencies may replicate. Substantial research has
demonstrated its effectiveness.

The next modules give practitioners information
about the core processes for providing FPE services.

Basic Elements and Practice Principles 9 Module 1

Exercise: Explore the Benefits of Family Psychoeducation

Studies that have explored what makes a difference in whether practitioners adopt a new approach to
treatment have found that practitioners are more likely to adopt a practice if it addresses an area in which
they feel they must improve. Share your experiences about where the traditional service delivery system
has been inadequate and identify aspects of FPE that address those inadequacies.

Some experiences where the traditional service delivery system has been inadequate:

n
n
n
n
n
n

How Family Psychoeducation may address those inadequacies:

n
n
n
n
n
n

Basic Elements and Practice Principles 11 Module 1

Exercise: Examine Program Standards

n Distribute these documents:

o Family Psychoeducation Fidelity Scale;

o General Organizational Index; and

o Outcome measures that your agency will monitor (if available).

n Discuss how your Family Psychoeducation program will be evaluated based on these program standards.

The Core Processes of Family Psychoeducation 13

Module 2

Module 2

The Core Processes of Family Psychoeducation
Notes to the family intervention coordinator

Prepare for Module 2:

n Make copies of Module 2. Your copy
is in this workbook; print additional
copies from the CD-ROM in the KIT.

n Distribute the material to those who are
participating in your group training. Ask them
to read it before meeting as a group.

n  Make copies of these exercises:

o Identify Consumers and Families

o Introduce Your Program

Do not distribute the exercises until the group
training. Your copies are in this workbook;
print additional copies from the KIT’s CD-ROM.

n Make copies of your agency’s policies and
procedures for identifying consumers for
FPE and discharging them from the program
(if available). Guidelines for developing these
policies are provided in Building Your Program
in this KIT.

Conduct your second session:

n When you convene your group, discuss the
content of Module 2.

n Distribute the following:

o Your agency’s policies and procedures for
identifying consumers for FPE and discharging
them from the program

o Exercises for this module

Note: This module has no corresponding Practice
Demonstration Video component.

The Core Processes of Family Psychoeducation 1 Module 2

 
Training Frontline Staff

Module 2: The Core Processes
of Family Psychoeducation

Module 2 introduces you to the core processes of Family Psychoeducation, including
joining with consumers and families, offering education, and understanding the
nature of ongoing Family Psychoeducation (FPE) sessions. This module also discusses
the goals and objectives of each phase of the program.

Core processes of Family Psychoeducation

n Consumers are identified as potential
participants.

n Practitioners introduce Family
Psychoeducation to consumers.
Consumers who are willing to
participate identify potential family
members.

n Practitioners meet individually three
or more times with consumers and
families. The purpose of these joining
sessions is to engage consumers and
families in a working alliance.

n Once practitioners have finished
joining sessions with five to eight
consumers and their respective
families, they offer a 1-day
educational workshop.

n After completing the 1-day
educational workshop, practitioners
ask consumers and families to attend
ongoing Family Psychoeducation
sessions offered in either single-family
or multifamily group format.

n Ongoing Family Psychoeducation
sessions continue for 9 months or
more. Practitioners, consumers, and
families use a structured problem-
solving approach to define and
address current issues.

n Practitioners document consumers’
progress using Progress Notes tailored
to each phase of the program.

n Practitioners meet weekly with the
family intervention coordinator for
group supervision.

Module 1 2 Basic Elements and Practice PrinciplesModule 2 2 The Core Processes of Family Psychoeducation

Although you might think that integrating Family
Psychoeducation (FPE) core processes and
paperwork into your daily routine is too time
consuming and burdensome, these processes
ensure that FPE services are effective and efficient.

Identify consumers

FPE is effective for a wide variety of consumers.
However, some evidence shows that FPE is
particularly beneficial for consumers and families
with the following characteristics:

n Consumers who have recently experienced their
first episode of mental illness or are early in the
course of illness;

n Consumers who are experiencing acute
psychiatric crisis;

n Consumers who experience frequent
hospitalizations or prolonged unemployment;

n Consumers or families who have asked to learn
more about serious mental illnesses;

n Families who have previously benefited from
a family education program and want to learn
how to better support their relative; or

n Families who are especially exasperated
or confused about the illness.

FPE is particularly effective in working with
families and consumers who are early in the course
of illness, because most consumers and families
report the most extreme distress during this time.
Often in this early period, major rifts develop
between consumers and families that may
exacerbate symptoms and disability. FPE has
prevented and often healed those rifts, as
participants stop blaming themselves or one
another and cooperate to help in the overall
treatment and rehabilitation process.

Initially many agencies choose to offer FPE to
consumers with schizophrenic disorders because
the evidence for this model is strongest with this
group. Once you have provided FPE services to
consumers with schizophrenic disorders and their
families, it relatively easy to modify your FPE
program to provide services to families and
consumers who have other diagnoses.

The number and types of consumers you identify
depend on whether you offer FPE in a multifamily
or single-family group format. If your agency
intends to offer ongoing FPE services primarily
in the multifamily format, identify five to eight
consumers with similar diagnoses and offer
multifamily group sessions to them. If your agency
chooses to offer FPE in a single-family format, the
number of consumers you should identify depends
on the size of your FPE program.

During this training, your family intervention
coordinator will review your agency’s policies and
procedures for identifying consumers for FPE.

Introduce the program

Once your family intervention coordinator assigns
consumers to your caseload, set up a face-to-face
meeting to introduce them to the FPE program.
In the meeting, emphasize that the program is for
both consumers and their family members. While
some psychoeducation programs are solely for
either consumers or family members, FPE services
are provided to both simultaneously.

Emphasize that participating in FPE is the
consumers’ choice. After discussing the benefits
and structure of the FPE program, ask consumers
if they would like to identify a family member
with whom they would participate in the program.
Remember, the term family includes anyone who
consumers believe is supportive and would like to

The Core Processes of Family Psychoeducation 3 Module 2

participate in FPE. Therefore, consumers may
identify people who are not blood relatives.

Most consumers welcome family involvement when
it is clear that the goal is to help families better
understand their illness and build support to help
them achieve their personal recovery goals.
However, if consumers are not interested in the
program, respect their decision.

Confidentiality

Some states require that consumers sign a Release
of Information Form before you may contact their
family member. Your family intervention
coordinator should review your agency’s
confidentiality requirements as a part of this
training. For more information, see Building Your
Program in this KIT.

Length of the FPE program

Although the goal is to offer ongoing FPE services,
some consumers and families may be initially
unwilling to make long-term commitments.
Instead, when you introduce FPE, simply ask
consumers and families to participate for as long as
they find it useful. Often once people participate
for a few sessions, they choose to stay long term,
especially in multifamily groups.

Conduct joining sessions

Once consumers agree to participate in FPE and
identify a family member, arrange to meet with
them. These initial introductory sessions are called
joining sessions.

Joining sessions are considered the first phase of
the FPE program. Complete this phase by meeting
with consumers and families at least three times for
approximately 1 hour.

The overall purpose of joining sessions is to
engage consumers and families in a working
alliance. This working alliance is essential to
providing effective FPE.

Each joining session has distinct goals and
objectives (see Module 3). Some of the goals
of joining sessions are as follows:

n Understand consumers’ and families’ unique
experiences and view of mental illnesses;

n Learn about consumer and family strengths
and resources in coping with mental illnesses;

n Develop mutual, specific goals; and

n Instill hope and an orientation toward recovery.

You may hold joining sessions with consumers and
their respective family members together or meet
separately with them. (That means you would
conduct six or more sessions instead of three
or more.)

When deciding whether to meet with consumers
and families jointly or separately, consider the
following:

n Consumer and family preferences;

n Consumer diagnosis and illness characteristics;
and

n The goals of the session.

Tell consumers and families that it is common to
meet with them individually and jointly with their
respective family members in the first phase of the
FPE program. Ask consumers and families how they
feel about joint and separate meetings. Logistical
arrangements such as transportation or work
schedules sometimes dictate whether consumers
and families can meet jointly. Discuss preferences
and logistical factors during your first meeting.

Decisions for offering joining sessions separately
or jointly are also based on diagnosis and illness
characteristics. For example, recent studies show
that joining sessions for consumers with bipolar
disorder are more effective when conducted

Module 1 4 Basic Elements and Practice PrinciplesModule 2 4 The Core Processes of Family Psychoeducation

separately (Moltz, 1993). Use your professional
discretion to determine how best to accomplish
the goals of each session. See Module 3 for more
information.

It is important to fully complete this phase before
you offer ongoing FPE sessions. Practitioners
who shortchange this process often experience
difficulties keeping consumers and families
engaged in FPE services.

Conduct the educational
workshop

Once you meet the goals of the joining sessions,
you are ready to offer the second phase of the
FPE program. In this phase, you will ask family
members to attend a 1-day educational workshop.

Following a structured educational curriculum,
the workshop is usually conducted in a formal,
classroom setting. Two FPE practitioners who have
completed joining sessions with consumers and
families facilitate the workshop. The treating
psychiatrist and other treatment team members
are often invited to conduct part of the presentation.
For more information about the structure and
content of this workshop, see Module 3.

Typically the workshop is conducted solely with
families—not with consumers—to give families
a chance to get acquainted. The opportunity to
interact with others who are in similar situations
and to speak freely about their experiences
allows families to bond and develop supportive
relationships. It also increases families’
commitment to participate in FPE.

Some agencies involve consumers in part of the
workshop to ensure that they receive the same
educational information as their families. Others
offer this information to consumers individually
or in a separate consumer forum.

Use professional discretion to decide which
educational format will be most effective for the
consumers in your program. Consider the severity
of consumers’ symptoms and their cognitive ability
to absorb educational material when it is provided
in the joint format. For example, recent studies
show that joint educational sessions are effective
for consumers with nonepisodic bipolar disorder
(Moltz, 1993; Miklowitz & Goldstein, 1997).

If you plan to offer ongoing FPE sessions in a
multifamily group format, complete at least three
joining sessions with five to eight consumers and
their respective family members before conducting
the 1-day workshop. To ensure that consumers and
families remain engaged, offer the workshop within
1 or 2 weeks after you complete the joining sessions.
You may need to carefully coordinate this.

Offer ongoing Family
Psychoeducation services

After completing three joining sessions and the
1-day workshop, ask consumers and families to
attend ongoing FPE sessions. The third phase
of the FPE program consists of providing ongoing
FPE sessions for 9 months or more. You may
provide these sessions in either the single-family
or multifamily group format.

Choose a format

The format that you choose will depend on
consumer and family preferences and needs.
In general, single-family formats tend to be used
for the following:

n Consumers and families with strong social
support networks;

n Consumers and families who exhibit unusual
resilience or strong coping skills; or

n Consumers who response positively
to medications;

The Core Processes of Family Psychoeducation 5 Module 2

Multifamily groups tend to be used for the
following:

n Consumers who are experiencing their first
episode with mental illness;

n Consumers who are not responding well
to medication and treatment;

n Consumers who are experiencing other
complicating issues such as additional
medical illnesses;

n Families experiencing high stress;

n Families who have separated from their
relative with mental illness; and

n Families who have been through divorce.

Although initially consumers and families may
be reluctant to participate in a group, multifamily
groups benefit both consumers and their families.
For example, the social stigma related to mental
illnesses causes many consumers and families to
feel socially isolated. FPE in a multifamily group
format connects consumers and families to others
with similar experiences. It gives them a forum
for peer support and mutual aid by allowing
participants to share solutions that have worked
for them. For this reason, we recommend offering
ongoing FPE services in a multifamily group
format, whenever possible.

FPE multifamily groups consist of five to eight
consumers and their respective family members.
They meet every 2 weeks for 1½ hours. Two FPE
practitioners co-facilitate the group.

In the single-family format, one FPE practitioner
meets with one consumer and his or her family
members. Meetings are usually every 2 weeks
for 1 hour.

FPE practitioners commonly work in both
multifamily or single-family group formats.
For example, when multifamily group members
are unable to attend specific group sessions, you
may offer single-family sessions to accommodate
scheduling difficulties.

Use single-family sessions to re-engage consumers
and families who no longer participate in FPE
services. You may also offer single-family sessions
to consumers and families who have completed
an FPE multifamily group. Offer these sessions
as needed to sustain ongoing family support
and involvement.

If your agency is only able to offer ongoing FPE in
a single-family format, refer consumers and families
to local support groups to ensure that they can
benefit from peer support and mutual aid.

Focus on current issues

The goal of ongoing FPE sessions is to identify the
current issues that consumers and families face, and
to partner with them to address these issues. FPE
practitioners commonly use a structured problem-
solving approach, provide information, and teach
communication, coping, and social skills.

In general, FPE sessions reinforce the information
learned in the educational workshop and focus
on consumers’ personal recovery goals, which
generally fall into the following categories:

n Issues related to re-entering the community; or

n Issues related to social and vocational
rehabilitation.

Issues related to re-entering the community

Consumers who are experiencing or recovering
from acute episodes for which they have been
hospitalized often have issues related to re-entering
the community. Personal recovery goals may relate
to the following:

n Coping with symptoms;

n Medication; and

n Alcohol and substance use.

At times, the symptoms of mental illnesses may
interfere with consumers’ ability to process
information presented either verbally or in writing.

Module 1 6 Basic Elements and Practice PrinciplesModule 2 6 The Core Processes of Family Psychoeducation

Consequently, communication issues are common.
Use communication and coping skills training to
address these issues.

Communication skills training helps consumers
and families learn new methods of interacting
to address cognitive difficulties. These skills
are especially useful for consumers who have
experienced complications or have not responded
well to treatment. Their families may feel
exasperated and, consequently, may exacerbate
their relative’s symptoms.

In ongoing FPE sessions, model simple and direct
communication for family members. Reinforce the
importance of communicating in a low, calm tone
to counteract sensitivity to stimulation. Other
techniques include breaking information down into
small chunks and engaging consumers to ensure
that they receive information accurately.

When communicating important ideas, encourage
consumers and families to set aside a specific time
to talk. Doing so gives consumers and families an
opportunity to rehearse the communication skills
that they learn during FPE sessions.

Coping skills training helps consumers and families
learn new or enhance existing strategies to manage
stress, problems, or persistent psychiatric
symptoms. Steps used in coping skills training
include the following:

1. Identify a problem or persistent symptom.

2. Conduct a behavioral analysis to determine
situations in which the symptom is most
distressing.

3. Identify coping skills that consumers used
in the past.

4. Evaluate the effectiveness of previously
used coping skills.

5. Increase the use of effective coping skills.

6. Identify new coping skills to try.

7. Model and practice new coping skills in role plays.

8. Gain feedback on the effectiveness of the new
coping skills and the increased use of previously
used ones.

9. Further tailor or adapt the coping strategies
to meet consumers’ needs.

Coping strategies range from relaxation to
cognitive-behavioral techniques. Practicing new
coping skills is most effective when consumers
involve family members and other supporters.
For more information, see the Illness Management
and Recovery KIT.

Issues related to social and vocational
rehabilitation

For consumers who are in the rehabilitation phase,
FPE sessions focus on their unique recovery goals.
Consumers commonly identify situations that are
likely to cause stress or barriers to achieving their
goals. Use problem-solving, social skills training,
and role plays to address these issues. For more
information, see Modules 4 and 5.

Engage consumers and families
continuously

Engaging consumers and families in FPE starts the
moment that they are referred to the program. It is
difficult, if not impossible, to engage consumers
and families in any meaningful way unless you
know their needs and goals. For this reason, we
suggest conducting three or more joining sessions
to build a rapport and a working alliance. Once
consumers and families are involved in ongoing
FPE sessions, your challenge is to focus FPE
services on helping them meet their immediate
needs and goals.

The engagement process never stops. Whenever
you meet with consumers and families, you learn
more about them. If you want consumers and
families to stay engaged, you must continue to help
them progress in a way that is meaningful to them.

The Core Processes of Family Psychoeducation 7 Module 2

Some consumers and families have had negative
experiences with specific practitioners or with
mental health services. Discussing these experiences
during joining sessions can help to overcome them.
It may take some consumers and families a while
to realize that you offer something different from
what they have received in the past.

At any point, if consumers and families disengage
from the FPE program, assertively reach out to
engage them again. Contact consumers and
families on an ongoing basis through a variety of
means (by phone, mail, etc.). When appropriate,
offer to meet with consumers and families in their
home or their community. Gently encourage and
demonstrate tolerance of different levels of
readiness by offering flexible services to meet
consumer and family needs.

Complete Progress Notes

After every FPE session, fill out an FPE Progress
Note to document the services that you provided.
The Progress Notes will help you demonstrate that
you did the following:

n Met the goals of each joining session;

n Provided all components of the educational
workshop; and

n Followed the structured problem-solving
approach.

Progress Notes also help you track consumer
and family goals, and the progress that they make
toward achieving them. Make sure that the goals
consumers develop in the FPE program are
reflected in their treatment plan.

Ask your family intervention coordinator for a copy
of FPE Progress Notes tailored to each phase of the
FPE program.

Participate in supervision

It is important for new FPE practitioners to
receive supportive supervision. As part of an FPE
team, you are expected to meet weekly with your
family intervention coordinator for individual or
group supervision. Weekly supervision meetings
are critical to coordinate the timing of joining
sessions and the educational workshop, to answer
questions about the model, and to reinforce FPE
skills and techniques.

Talk with your family intervention coordinator and
fellow FPE practitioners about how to best respond
to issues that arise in your FPE sessions. Discuss
consumers’ goals and the progress that they are
making toward their recovery.

Every 6 months, your family intervention
coordinator will also present the results and
recommendations from your FPE fidelity
assessment. Discuss this information as a team
to determine how your FPE program may be
improved. For more information about the FPE
fidelity assessments, see Evaluating Your Program
in this KIT.

Summary

In summary, this module introduced the core
processes of FPE, including joining with
consumers and families, offering education,
and understanding the nature of ongoing FPE
sessions. The next module discusses two of these
processes—joining sessions and educational
workshops—in greater detail.

The Core Processes of Family Psychoeducation 9 Module 2

Exercise: Identify Consumers and Families

Answer the following questions to help reinforce your understanding of your agency’s FPE policies
and procedures.

1. What are your agency’s policies for identifying and referring consumers to your FPE program?

n
n
n
n

2. Under what circumstances will consumers be discharged from FPE?

The Core Processes of Family Psychoeducation 11 Module 2

Exercise: Introduce Your Program

n Role play: Conduct a role play to practice introducing your FPE program. Select three group members
to play the roles of consumer, family, and practitioner.

n Group discussion: Discuss how you would engage a family member who is overcoming negative
experiences with the mental health system.

Joining Sessions and Educational Workshops 13

Module 3

Module 3

Joining Sessions and Educational Workshops
Notes to the family intervention coordinator

Prepare for Module 3:

n Make copies of Module 3. Your copy
is in this workbook; print additional
copies from the CD-ROM in the KIT.

n Distribute the material to those who are
participating in your group training. Ask them
to read it before meeting as a group.
n  Make copies of these exercises:

o Review Progress Notes for Joining
Sessions and Educational Workshops

o Practice What You’ve Learned About Joining
Sessions

Do not distribute them until the group
training. Your copies are in this workbook;
print additional copies from the CD-ROM.

n Make copies of your agency’s
Progress Notes tailored to joining
sessions and educational workshops.

Conduct your third training session:

n  When you convene your group, view
the following segments of Practice
Demonstration Video (approximately
30 minutes):

o Introduction

o Joining with Individuals and Families

o

Joining Session 1

o

Joining Session 2

o

Joining Session 3

o Educational Workshop

n Discuss the video and the content of Module 3.

n Distribute the exercises and Progress Notes and
complete them as a group

Joining Sessions and Educational Workshops 1 Module 3

Training Frontline Staff

Module 3: Joining Sessions
and Educational Workshops

Module 3 provides details on two phases of the Family Psychoeducation program:
joining sessions and educational workshops. Completing these phases is essential
to the process of engaging consumers and families both initially and throughout
the program.

Joining sessions

Joining sessions are the first phase in the
Family Psychoeducation (FPE) program.
FPE practitioners meet three or more
times with each FPE consumer and their
respective family members. Meetings
typically last for 1 hour.

The purpose of joining sessions is
to build rapport, convey hope, and
engage consumers and families in
a working alliance.

Develop a working alliance

Joining means to connect, bring together,
or unite. Developing a working alliance
with consumers and families is essential
to providing effective FPE. Agencies
that shortchange this process often have
difficulties keeping consumers and families
engaged in FPE services.

In these alliances, FPE practitioners ask
consumers and families to partner with
them in the treatment process. Consumers
and families help carry out the treatment,
rather than participate as objects
of treatment.

Module 1 2 Basic Elements and Practice PrinciplesModule 3 2 Joining Sessions and Educational Workshops

The object of treatment is the illness, not
consumers or families. This may appear to be a
matter of semantics to some, but the differences
are a key for providing effective services. FPE
practitioners work with, not on, consumers
and families.

FPE practitioners recognize consumers’ and
families’ vast knowledge and expertise. The
working alliance is built on the idea that FPE
practitioners, consumers, and families join their
expertise and strengths to support consumers
in achieving their personal recovery goals. This
collaborative approach is the foundation for the
evidence-based model.

To foster this relationship, FPE practitioners do
the following:

n Demonstrate genuine concern for consumers
and their families;

n Validate consumers’ and families’ experiences;

n Avoid treating consumers or families as patients;
and

n Avoid blaming consumers or families for causing
the mental illness.

To create a relaxed, informal atmosphere, FPE
practitioners set the stage for forming a working
alliance by socializing at the beginning and end
of each joining session. Socializing helps decrease
anxiety and allows you to get to know consumers
and family members as people beyond the
illness. To engage consumers and families, FPE
practitioners are also open and forthcoming about
who they are as people.

From the first meeting, practitioners actively guide
the conversation. Because each joining session has
tasks to be completed, you must structure them.
Following a prescribed structure reassures both
consumers and families, letting them know what
to expect and what will be accomplished. The tasks
for each joining session are described on the
following pages.

Joining Sessions and Educational Workshops 3 Module 3

Joining Session 1

Purpose: To develop a rapport and build a working
alliance with consumers and families.

Developing a rapport and building a working
alliance is a long process. It is important to build
the relationship beyond the illness, so keep your
manner positive, informal, and collegial. Begin the
joining session by socializing. After socializing,
review the session’s agenda.

If your first contact with consumers and their
families is during an acute psychiatric episode,
you may have a special opportunity to build a
strong working alliance. Respond quickly to the
immediate needs that consumers and families
present. Demonstrate willingness to help,
especially in concrete ways.

Establish yourself as a resource and support.
If consumers and families seek particular
assistance, offer it. Prompt attention reassures
both consumers and families and demonstrates
your commitment to partnering with them in
consumers’ recovery process.

Do not be afraid to step in and take on roles not
traditionally practiced. You may act as an advocate
in navigating the mental health system, make a
referral for more services, or even help consumers
and families obtain entitlements or benefits.

If consumers are not currently experiencing an
acute psychiatric episode, review the last episode
that they experienced. Identify precipitating events
and early warning signs with consumers and
families. To do so, guide them through a review
of the previous weeks. Emphasize any changes in
consumers’ symptoms, thoughts, or feelings during
that time. These changes—which may be either
quite apparent or barely noticeable—constitute the
prodromal signs and symptoms for that consumer.
In most cases, idiosyncratic behaviors come before

more common prodromal symptoms, for example,
poor sleep, anorexia, pacing, restless behaviors,
and irritability. These behaviors become even more
important in the future to help prevent relapse.

Next, ask both consumers and their families how
they coped with symptoms. Explore the types of
strategies that were helpful and those that were
not. It is important to understand consumers’ and
families’ unique experiences with mental illnesses.

Managing an acute psychiatric episode is always a
difficult experience. Show that you appreciate this
fact and validate the feelings that consumers and
families share. Relate in a humanistic, caring, and
hopeful manner.

Some practitioners skip or shorten this phase of the
FPE program to more rapidly begin clinical work.
However, shortchanging this step usually backfires
since consumers and families who do not complete
joining sessions are more likely to disengage
prematurely from FPE services.

 

Tasks for Joining Session 1

n Socialize.

n Review a present (or past) acute psychiatric
episode.

n Identify precipitating events.

n Explore prodromal signs and symptoms.

n Review family experiences in providing
support and validate their experience as
normal human responses.

n Identify consumer and family strengths and
coping strategies that have been successful.

n Identify coping strategies that have not
been helpful.

n Socialize.

Module 1 4 Basic Elements and Practice PrinciplesModule 3 4 Joining Sessions and Educational Workshops

Joining Session 2

Purpose: To explore the emotional impact of serious
mental illnesses.

In general, you may conduct joining sessions either
jointly or separately, depending on consumer and
family preference. However, hearing about
families’ frustration and anger about the effects
of consumers’ symptoms is usually best done
in an individual session. For this reason, FPE
practitioners often choose to conduct this session
separately for consumers and their families.

Begin and end each joining session by socializing
to reduce anxiety and set the tone for developing
a working alliance. Encourage consumers and
families to discuss the impact that serious mental
illnesses have had on their lives. Support, validate,
and recognize normal human reactions such as
feelings of loss, despair, grief, anger, frustration,
and guilt associated with serious mental illnesses.

Next, learn about consumers’ social support
network. You may complete a genogram (a visual
representation of family relationships simialr
to a family tree) during the session. Remember
to define social supports broadly by including
neighbors, landlords, employers, or any other
supportive people.

It is also important to understand the experiences
that consumers and families have had with the
mental health system. When those experiences
are left unexpressed, they can form a barrier
to developing a strong working alliance, cause
repetitive complaints, and hinder your ability to
work on current issues. Acknowledge and validate
feelings such as anger or frustration to help

consumers and families overcome past negative
experiences and allow progress to be made.

Many consumers and family members feel that
mental health practitioners blame and criticize
them. Blaming consumers or families for the
illness is not constructive or helpful and should
be avoided.

Share basic information about consumers’ mental
illnesses. Demonstrate the resources that you have
to offer while showing respect for consumers’
and families’ first-hand experience in managing
their illnesses.

Convey optimism that consumers will be able to
reduce relapses and achieve their personal recovery
goals by partnering in the treatment process.
Having answers for every question is less important
than conveying a commitment to working together
to find solutions.

 

Tasks for Joining Session 2

n Socialize.

n Explore feelings and reactions to having
a mental illness or a relative with a mental
illness.

n Identify consumers’ social support network.

n Construct a genogram or family tree.

n Review past experiences with the mental
health system.

n Convey basic information about the
consumer’s specific mental illness.

n Socialize.

Joining Sessions and Educational Workshops 5 Module 3

Joining Session 3

Purpose: To identify consumer and family strengths,
interests, and goals and to introduce the next
phases of the FPE program.

If you schedule consumers and their families to
meet separately for this session, consider meeting
with consumers first. After exploring consumers’
strengths and interests, work with them to identify
goals they would like to work on during the FPE
program. Setting and pursuing personal goals is an
essential part of recovery. In FPE, consumers
define what recovery means to them and identify
three short- and long-term goals.

Explain to consumers that people are often more
effective in getting what they want when they set
clear goals. Help consumers identify goals by
reviewing areas of their lives with which they are
satisfied and those that they wish to change. Once
consumers identify one or two areas on which they
would like to work, help them break the areas down
into smaller goals or steps that can be achieved
within the next few months. Start with goals that
are relatively small.

Introduce consumers to the last two phases of the
program—the 1-day educational workshop and
ongoing FPE services. Describe the benefits of
giving information to family members and say that
you would like to invite family members to attend
the 1-day educational workshop. Tell them about
the format and components of the standardized
educational curriculum. If your agency plans to
involve consumers in part of the workshop or to
offer a parallel workshop for them, describe those
details and invite consumers to attend.

Next, describe the last phase—ongoing FPE
sessions. Review the goals that consumers identified
earlier and ascertain their support for working on
them. Explain that ongoing FPE sessions will focus
on supporting their efforts to achieve those goals.
Introduce the structured problem-solving approach
and explain that this is one tool they can use to

pursue personal goals. Ask consumers if you may
share their interests and goals with their family
members. Tell them that you may offer ongoing
FPE sessions in a single-family or multifamily
group format and describe the benefits of
participating in multifamily groups. Ask if they
would be willing to participate with their families.
If consumers are unsure, continue to explore the
decision during additional single-family sessions.

Once consumers give their permission to share
their interests and goals with family members,
meet with their family member for a third joining
session. Review consumers’ interests and goals and
ascertain family support for those goals. If family
goals differ from the consumer’s goals, probe to
fully understand the differences. When possible,
search for common ground.

Next, introduce family members to the last two
phases of the FPE program. Review the benefits
of participating in the workshop and multifamily
group sessions. Ask about their experiences in
attending group sessions and what concerns they
might have, including confidentiality, shyness,
and feeling pressured to speak in groups or in the
workshop. Assure them that they may contribute
only as much as they wish. If families are unsure
about continuing with the next two phases of the
FPE program, schedule additional joining sessions
as needed to continue the engagement process.

 

Tasks for Joining Session 3

n Socialize.

n Identify personal strengths, hobbies,
interests.

n Identify short- and long-term goals.

n Introduce the next phases of the FPE
program.

n Socialize.

Module 1 6 Basic Elements and Practice PrinciplesModule 3 6 Joining Sessions and Educational Workshops

Pacing and format

The pacing of joining sessions and whether you will
be able to complete these tasks in three sessions
will depend on individual circumstances. For
example, if a consumer is in crisis, you might need
to shorten the initial joining sessions and complete
these tasks by conducting additional sessions.

You may choose to conduct joining sessions jointly
with consumers and families or with consumers
and families separately. As discussed in Module 2,
decisions about the format may be influenced by
consumer and family preferences, diagnosis and
illness characteristics, and the goals of the session.
For example, FPE practitioners often schedule
separate sessions to discuss highly personal matters
such as romantic entanglements, drug abuse,
or sexual side effects of medications.

Others believe that it is easier to engage consumers
and families if they have at least one individual
joining session. They believe that doing so allows
consumers and families to speak more openly.
Use your professional discretion for these decisions
and remember to remain flexible and responsive.

Educational workshops

Education is one of the essential ingredients
of FPE. This section introduces you to a
recommended standardized curriculum that you
may use to teach families about their relatives’
mental illnesses. Information about the timing,
structure, and format of the 1-day educational
workshop is also outlined below.

Why offer informational resources?

When people do not have accurate information
about mental illnesses, they may adopt mistaken
beliefs or rely on intuition. Unfortunately, many
effective interpersonal and rehabilitative
approaches are often counter-intuitive.
Consequently, despite having their relative’s best
interest in mind, their actions may interfere with
recovery. Therefore, it is important to give families
the information and guidance they need to promote
recovery and rehabilitation.

Information can help create a shared language that
allows consumers, families, and practitioners to
work together. The first message is that no one is
to blame for mental illnesses. Blaming consumers
or families is not constructive or helpful.

Next, families must understand basic information
about their relative’s serious mental illnesses. One
critical aspect of family education is that it gives
families hope that they will be able to alter the
course of illness.

Joining Sessions and Educational Workshops 7 Module 3

Timing

You must respond to the immediate needs of
consumers and families and answer questions as
they arise. For this reason, the educational process
begins during the first joining session and continues
throughout each phase of the FPE program.

While education is ongoing, the main focus on
education occurs in the second phase of the FPE
program. Once consumers and their respective
family members have completed three or more
joining sessions, invite family members to attend
a 1-day or 8-hour educational workshop. Typically,
the 1-day workshop is offered to a group of
family members.

During the joining sessions, explain the nature
and purpose of the workshop. Explain that family
members will be expected to attend this type of
workshop only once as a part of their participation
in the FPE program.

If you offer ongoing FPE sessions in a multifamily
group format, plan to have the five to eight families
who will participate in the multifamily group attend
the same workshop. The workshop gives them an
opportunity to get acquainted before the
multifamily group begins.

Schedule the workshop for a time that meets the
needs of family members. Typically, workshops
are held on weekend days.

Participants

The workshop is most often conducted solely
with families—not with consumers—to give
families a chance to get acquainted. The
opportunity to interact with others who are in
similar situations and to speak freely about their
experiences allows families to bond and develop
supportive relationships. It also increases families’
commitment to participate in FPE.

Some agencies involve consumers in part of the
workshop to ensure that they receive the same
educational information as their families. Others
offer this information to consumers individually
or in a separate consumer forum. For more
information about providing information about
mental illness to consumers, see the Illness
Management and Recovery KIT.

Educational curriculum

We recommend using the following standardized
curriculum to teach families about mental illnesses.
To provide enough specific information, we
recommend that workshops focus on one specific
mental illness. For example, all family members
would have relatives with schizophrenic disorders
and the information presented would relate
primarily to these disorders.

 

The Educational Curriculum

Cover

s
Six Topics

n Psychobiology of the specific mental
illness including the basics of brain
function and dysfunction, and the possible
causes of the mental illness

n Diagnosis including symptoms and
prognosis

n Treatment and rehabilitation including
an overview of treatment options and how
they promote effective coping and illness
management strategies

n Impact of mental illnesses on the
family including how mental illnesses
affect families as a whole

n Relapse prevention including prodromal
signs and symptoms, and the role of stress
in precipitating episodes

n Family guidelines or recommended
responses to help families maintain a
home environment that promotes relapse
prevention

Module 1 8 Basic Elements and Practice PrinciplesModule 3 8 Joining Sessions and Educational Workshops

Presenter selection

Family members often feel more comfortable if the
practitioner who knows them and their consumer
relative facilitates the workshop. For this reason,
we recommend that the same FPE practitioners
conduct the joining sessions, educational workshop,
and ongoing FPE sessions.

Two FPE practitioners usually facilitate the
workshop. Facilitators are not expected to be
experts in all areas of the educational curriculum.
Instead, they choose to present areas in which
they are comfortable and invite colleagues with
particular areas of expertise to present the
remaining educational components. For example,
the treating psychiatrist should present the material
on the psychobiology of the specific mental illness.

Once you have selected all of the presenters and
assigned them areas of the educational curriculum,
schedule a practice presentation to review the
materials before the workshop. Practicing with
colleagues helps increase confidence and gives
an opportunity for feedback on clarity and rate of
speech. It may help to videotape or audiotape the
practice presentations and to rehearse responses
to common questions.

Educational techniques

The roles of educator may be new for FPE
practitioners. When educating consumers and
families, keep the following techniques in mind:

Use an interactive, not didactic teaching style

Teaching in an interactive style makes learning
an interesting, lively activity. Interactive learning
involves frequently pausing when presenting
information to get consumer and family reactions
and perspectives. Talk about what the information
means and answer any questions that may arise.
An interactive teaching style conveys to consumers
and families that they have important contributions

to make to the learning process and that you are
interested in what they say.

Present the material in a conversational tone by
summarizing the key points and giving relevant
examples. Avoid the monotony of having just one
person speak. At all times, communication should
be two-way; it must never seem like a lecture.
People learn information by actively processing
it in a discussion with someone else.

Periodically review information that you
already covered

Begin and end each segment with a brief summary
of the key points. Make connections between
previously learned and new material. To check if
consumers and families retained the information
and to reinforce topics that you previously
discussed, ask them to summarize what
they remember.

Adopt common language to facilitate
communication

People have their own ways of understanding their
experiences, thinking about their lives, and looking
into the future. The more you can speak the same
language, the easier it will be to make connections
and avoid unnecessary misunderstandings.

Break information down into small chunks

Some mental illnesses cause impairment in
cognitive functioning, which can result in a slower
rate of processing and the need to present
information in very small chunks or in a simplified
format. When educating consumers, take into
account individual needs.

Consumers who are experiencing psychiatric
symptoms may need information to be presented
in different formats, individually, or in shorter
group sessions. By presenting small amounts of
information at a time, consumers can learn at their
own pace.

Joining Sessions and Educational Workshops 9 Module 3

Check for understanding

How often you check for understanding of the
information will vary from person to person.
Avoid asking yes or no questions. Have consumers
and families summarize information in their own
words. Hearing them explain their understanding
of basic concepts allows you to know which areas
they understood and which need clarification.

Multimedia education

Offer the information in the standardized
curriculum to families in a variety of formats such
as videos, slide presentations, lectures, discussion,
and question-and-answer periods. Give each family
member a folder with handouts of the information
that will be presented, as well as resource lists and
Web sites that they can use to find more information.

For example, you might want to include a copy
of the following Family Guidelines. During the
session, review each guideline in detail, and ask
family members for their reactions, questions, and
experiences. Illustrate the guidelines with examples
based on the kinds of problems that your families
described during joining sessions.

 

Family Guidelines

1. Go slow. Recovery takes time. Things will
get better in their own time.

2. Keep it cool. Enthusiasm is normal. Tone
it down. Disagreement is normal. Tone it
down, too.

3. Give each other space. Time out is
important for everyone. It’s okay to reach
out. It’s okay to say, “No.”

4. Set limits. Everyone needs to know what
the rules are. A few good rules keep
things clear.

5. Ignore what you can’t change. Let
some things slide. Don’t ignore violence.

6. Keep it simple. Say what you have to say
clearly, calmly, and positively.

7. Partner with your relative’s treatment
team. Understand your relative’s goals
and the steps outlined in their treatment
plan.

8. Carry on business as usual. Re-establish
family routines as quickly as possible. Stay
in touch with family and friends.

9. Do not use street drugs or alcohol.
They make symptoms worse, can cause
relapses, and prevent recovery.

10. Pick up on early warning signs.
Note changes. Consult with your
consumer relative and the treatment
team, if possible.

11. Solve problems step by step. Make
changes incrementally. Work on one thing
at a time.

12. Adjust expectations. Use a personal
yardstick. Compare this month to last
month rather than to last year or next year.

Module 1 10 Basic Elements and Practice PrinciplesModule 3 10 Joining Sessions and Educational Workshops

Tailor your curriculum

While we recommend that you follow a
standardized curriculum, your workshop will be
most effective if you tailor the information as much
as possible to the participants. Connecting families
who have relatives with similar diagnoses is only
the first step. Pay close attention to the educational

needs that families reveal in joining sessions and
emphasize this information in the workshop.
Responding to family needs is the key to keeping
them engaged in the FPE program.

To ensure that all components of the standardized
curriculum are covered, follow the agenda below.

Sample Agenda of the Educational Workshop

9:00–9:15 Coffee and socializing

9:15–9:30 Formal introductions and explanation
of the format for the day

9:30–10:30 Psychobiology and diagnosis
of the specific mental illness

Basics of brain function and dysfunction

Possible causes of the specific mental illness

Diagnosis

Symptoms

Prognosis

10:30–10:45 Coffee break and socializing

10:45–11:15 Psychiatric medications

How they work

Outcomes

Side effects

11:15–12:00 Other treatments options Overview of other treatment options

How they work
Outcomes

12:00–1:00 Lunch and socializing

1:00–3:00 The impact of mental illness
on the family

The needs of the consumer

The needs of the family

Common family reactions to the illness

Common problems that consumers and families face

What the family can do to help

Family guidelines

The problem-solving method

3:30–4:00 Wrap Up Question and answer period

Scheduling, logistical, and questions about
multifamily group sessions

Socializing

Agenda adapted from Anderson et al., 1986, p. 76.

Joining Sessions and Educational Workshops 11 Module 3

To start, offer refreshments in an informal setting to
prompt spontaneous socializing. Have refreshments
available throughout the workshop. To develop an
atmosphere of partnership, during the breaks make
sure that you spend time with families, not solely
with colleagues.

To start the formal program, introduce yourself,
distribute the educational packets, and explain
the day’s agenda. For example, say:

Welcome and thank you for coming on this beautiful
Saturday morning! My name is Bob Smith and this
is Peg Rutherford. Some of you already know us
because we’ve been meeting individually for quite
some time now.

We want you to know as much as possible about this
illness—what’s known, and what’s not known, as of
now. Schizophrenia is a very complex and confusing
illness. We have found that the more information
family members have, the better equipped they are
to deal with problems as they occur.

This workshop is only one step of our work together.
After the workshop, we will regularly meet as a
group of families and consumers. We will continue
to give you relevant information and assistance.
We have found with the FPE program that working
together with consumers and families results in fewer
relapses and rehospitalizations.

We will answer as many questions as possible in this
workshop today. If we cannot answer something, we
will find someone who knows the information and
will get back to you.

While it is important to cover all components of
the standardized curriculum, present information
in an open, collegial manner that encourages
participation. Create an atmosphere that
encourages families to comfortably ask questions
and tailor the curriculum to respond to their needs.
It is important to continue the engagement process
and strengthen the working alliance.

By sharing experiences, families will discover
that their problems are similar. This realization

normalizes families’ experience with mental
illnesses and counters feelings of isolation.
They often begin to bond during the workshop
and build a strong social support network through
their contact in the multifamily group.

Invite family members to talk about their reactions
to the information presented. Some common
reactions are relief at finally knowing some facts,
anger at being kept in the dark, sadness, despair,
hopefulness about this approach, and eagerness
to get on with the work.

Keep in mind that family members are not
obligated to speak during the workshop. Respect
families’ decisions about how much they wish to
share by encouraging discussion and eliciting
reactions without demanding them.

If you have not done so already, outline the format
for multifamily groups, emphasizing the structured
problem-solving approach and its usefulness for
consumers and families. Present the agenda for the
first two meetings to generate enthusiasm for
upcoming sessions.

Give examples of how life has improved for
consumers and families who have participated
in FPE. End the workshop on a positive note. If
possible, families should leave the workshop feeling
optimistic about being involved in the FPE program.

If you have not done so already, share contact
information in case families need to reach you
between sessions. Make sure that you have
responded to the questions and concerns that
families have raised, especially questions about the
upcoming multifamily group. Thank all participants
for coming to the workshop.

This workshop is modeled after the workshop
described by Anderson and colleagues (1986).
For more information about conducting
educational workshops with consumers and
families, see The Evidence in this KIT.

Joining Sessions and Educational Workshops 13 Module 3

Exercise: Review Progress Notes for Joining Sessions and Educational Workshops

Distribute a copy of your agency’s FPE Progress Notes for joining sessions and educational workshops.
Review the components of these forms and discuss as a group.

Joining Sessions and Educational Workshops 15 Module 3

Exercise: Practice What You’ve Learned About Joining Sessions

Select three members of your training group to play the roles of practitioner, consumer, and family member.
Conduct role plays of Joining Sessions 1, 2, and 3.

Discuss the following:

n How would you engage a consumer who is reluctant to involve a family member in the FPE
program?

n How would you respond if consumers or family members become upset when discussing how
mental illness has affected their lives?

n How would you respond to a consumer or family member who shares past negative experiences
with group sessions?

Ongoing Family Psychoeducation Sessions 17

Module 4

Module 4

Ongoing Family Psychoeducation Sessions
Notes to the family intervention coordinator

Prepare for Module 4:

n Make copies of Module 4. Your copy
is in this workbook; print additional
copies from the CD-ROM in the KIT.

n Distribute the material to those who are
participating in your group training. Ask
them to read it before the group training.

n Make copies of the following
exercises:

o Practice What You’ve Learned About
Multifamily Groups

o Review the Progress Note for Ongoing Family
Psychoeducation Sessions

Do not distribute them until the group
training. Your copies are in this workbook;
print additional copies from the CD-ROM in
the KIT.

n Make copies of your agency’s Progress Notes for
ongoing FPE sessions (if available). For a model
form, see Building Your Program in this KIT.

Conduct your fourth training session

n When you convene your group, view
the last two segments on the Practice
Demonstration Video (approximately
50 minutes):

n Multifamily Groups

o Problem-Solving

o Discuss the video and content of Module 4.

n Distribute the exercises to the group and
complete them

Ongoing Family Psychoeducation Sessions 1 Module 4

Training Frontline Staff

Module 4: Ongoing Family Psychoeducation
Sessions

Module 4 describes the last phase of the program—ongoing Family Psychoeducation
sessions. When possible, these sessions should be offered in the multifamily
group format. For this reason, the module describes the first three sessions of the
multifamily group sessions in detail and draws applications to the single-family model.

Conduct ongoing Family
Psychoeducation sessions

Once consumers and families have
completed three or more joining sessions
and families have participated in the 1-day
educational workshop, invite consumers
and families to attend ongoing Family
Psychoeducation (FPE) sessions.

You may conduct these sessions in either
the single-family or multifamily group
format. Since you discuss and select format
options with consumers and families during
joining sessions, information for selecting
a format is presented in Module 2.

When possible, offer ongoing FPE sessions
in a multifamily group format. Multifamily
groups consist of five to eight consumers
and their respective family members.

Two FPE practitioners who have conducted
the joining sessions and educational
workshop facilitate the sessions.
Multifamily groups meet every 2 weeks
for 1½ hours. For consumers and families
to gain the full effectiveness of the FPE
program, offer ongoing FPE sessions
in either format for 9 months or more.

While this phase of the FPE program has
been found to be most effective when
offered long term, many FPE practitioners

Module 1 2 Basic Elements and Practice PrinciplesModule 4 2 Ongoing Family Psychoeducation Sessions

do not emphasize the long-term nature of FPE
during the engagement process. Asking consumers
and families to commit long term may provoke
anxiety. For this reason, tell consumers and families
that this last phase of the FPE program will
continue for as long as they find it helpful.

Structure of multifamily groups

The structure of the first two multifamily group
sessions differs from the structure of later sessions.
In the first two sessions, the goal is to establish
a partnership among group members. Up to this
point, the working alliance has been limited to
the consumer, family, and practitioner. When
consumers and families begin participating in
multifamily groups, the goal is to extend the
working alliance to include all group members.

Why structure the first two groups
differently?

Consumers and families need to get to know one
another apart from the effects of mental illnesses
on their lives. The first two sessions are designed
to help group members learn about one another
and bond as a group.

Traditional group therapy models emphasize
expressing feelings. This often sparks conflict
between family members, disagreement about the
group’s purpose, and anger or confrontation with
facilitators. Consequently, consumers and families
may become overwhelmed and give up on the
group. In contrast, FPE focuses on addressing
current issues that pose barriers to consumers’
personal recovery goals. Group members work
together by participating in a structured problem-
solving approach. For this approach to be effective,
group members must share ideas and be open to
accepting them. It is best to proceed slowly and
take time to develop trust and empathy.

Through the joining sessions, you developed
a working alliance with consumers and families
in the group. In the first two multifamily group
sessions, you will extend that partnership by giving
group members an opportunity to bond and build
their group identity.

Overview of the first session

The goal of the first session is for FPE practitioners,
consumers, and family members to get to know one
another in the best possible light. The first session
is not intended to be an opportunity to share deep
emotions and feelings about the illness or about the
group itself. Rather, it is a time for group members
to get to know one another and discover common
interests, issues, and concerns. For this reason,
encourage group members to talk about topics that
are unrelated to the illness, such as their personal
interests, hobbies, or daily activities.

Set up the room

Arrange chairs around a table or in a semi-circle
so that group members can easily see and hear
one another. Use the same setup at every session.
Be aware that once the problem-solving sessions
begin (after the second group session), groups
often like to be in a semi-circle so they can see
the blackboard, flipchart, or chalkboard.

Have refreshments available to prompt socializing
before and after the group. At the start of the
session, tell group members that they are free
to move around, get a drink, or use the restroom.
Make sure that consumers know they can leave
the room whenever necessary.

Ongoing Family Psychoeducation Sessions 3 Module 4

Be an effective facilitator

During the first two group sessions, be a good host.
Introduce group members, point out common
interests, and guide conversations to more personal
subjects such as interests and hobbies.

Act as a role model. Demonstrate by example that
you expect people to talk about topics other than
the illness. This means that you should be prepared
to share a personal story of your own.

Pay close attention to group members who speak
and thank them when they finish. Prompt reluctant
group members with questions or encourage them
to talk. Some group members may benefit from
a slow conversational pace to better absorb
information that they hear.

Think of the group in terms of any group of people
who meet one another for the first time. Guide the
conversation to topics of general interest such as
the following:

n Where people live;

n Where they were born and grew up;

n What kind of work they do both inside
and outside the home;

n What their hobbies are;

n How they like to spend their leisure time;

n Which recent movies they have seen; and

n What holiday or vacation plans they have.

Structure the first session

Welcome group members and review the format
for the first two sessions and future group sessions.
Begin with introductions. Group members
commonly want to talk about the illness during
their introduction. Guide the discussion by clearly
setting the agenda for the first group and modeling
the type of introduction that you expect. For
example, say:

Tonight, the goal is to begin to get to know one
another. Let’s go around the room and each say
something about ourselves. It is understandable to
want to talk about the effects of a mental illness, but
we will get to that during our next meeting.

Tonight, the goal is to talk about other parts of our
lives. Let’s start by sharing the things that we are
proud of. I would like to start by telling you about
myself.

If consumers and families have joined thoroughly
with you, they will feel less need to focus on the
illness during the first group session. When you
participate and talk about yourself, it gives the
group a model and creates a feeling of partnership.

Some FPE practitioners find it uncomfortable to
share personal information, since this is a departure
from the way of conducting traditional therapy
groups. However, you must create a friendly,
comfortable atmosphere among group members.
It may help to rehearse with your co-facilitator
ahead of time. Think of a few positive, engaging
stories about family, favorite activities, interests,
and hobbies.

Module 1 4 Basic Elements and Practice PrinciplesModule 4 4 Ongoing Family Psychoeducation Sessions

Be prepared to talk for about 5 minutes. For
example, say:

Hi, my name is Margaret Hanson. Some of you
have already met me, and some are meeting me
for the first time tonight. I am a social worker and
have worked in the community mental health center
for 15 years.

I grew up in this area and my parents still live in
the house I grew up in. I have three teenage girls
who keep my husband and me very busy and
challenged! Even though the girls are growing up
and going in different directions, we still like to do
things together as a family. One thing we like to
do is go camping.

Over the years, we’ve acquired a lot of equipment
so the girls could each invite a friend along on our
trips. This summer, we’re planning a trip to the White
Mountains, and we’re bringing two large canoes
since the girls are inviting friends. I especially enjoy
these trips since I don’t do much of the cooking—
my husband does! It’s so peaceful to camp and to
spend time in a less harried environment.

We have an old yellow lab that stays home when
we go camping, but when we’re home, she likes
to take me for a walk every morning, usually as
the sun comes up. In my spare time, I garden, scout
flea markets, spend time with friends, sew, and read.
Occasionally, my husband and I see a movie, go
out to eat with friends, or walk the beach when the
tourists aren’t around. Well, that’s enough about me
for now. I’m looking forward to getting to know all
of you better as time goes by.

Then turn to the next person and have group
members continue around the circle. Thank group
members after they contribute. Have your co-
facilitator sit halfway around the circle and take
a turn in sequence.

Redirect group members

If group members begin to talk about the illness or
the impact of the illness on their lives, redirect the
conversation. For example, say:

We will have time to talk about the illness later on.
For right now, let’s try to get to know other things
about one another.

Prompt group members

You may have to prompt some group members
who offer only a minimal amount of information.
Ask questions to help them give more details. For
example, if they like to watch television, ask which
shows they watch or if they say they like to cook,
ask which recipes they enjoy most. Strive to point
out similarities or interests that group members
share. For example, say:

I notice that several of us like to go to the movies.
Maybe we can talk about our most recent favorite
films.

This helps develop relationships and group
cohesion.

Ongoing Family Psychoeducation Sessions 5 Module 4

Overview of the second session

The second multifamily group session focuses
on how mental illnesses have changed the lives
of members in the group. In this session, the goal
is to continue building trust among group members
and help them develop a sense of a common
experience of having a mental illness or a relative
with a mental illness. The mood of this session is
usually less light-hearted than the first session, but
it is the basis for developing a strong group identity.

Structure the second session

Welcome members to the group as they arrive and
direct them to the refreshments. To start the group,
outline the agenda for the session by saying:

Thanks for being here tonight. Last time we spent
time getting to know one another. Tonight, let’s
begin by catching up for 15 minutes. Then we will
discuss how mental illnesses have affected our lives.

Begin the socializing with a comment or question
that is unrelated to the illness such as following up
with a group member about a planned activity or
event mentioned during the first session. It is
important to begin groups by socializing. Encourage
participation by modeling, pointing out connections
between group members, and asking questions.

After socializing, say:

Now it’s time to focus on our topic for the evening.
Mental illnesses have touched all of our lives in
some way. Tonight, you will each have a chance to
share your personal story of how mental illness has
affected your life. You can share as much or as little
as you would like, but also feel free to ask questions
and to support one another.

Start by sharing your own professional and personal
experience. For example, share a story about a
friend or family member with mental illnesses, talk
about how you became interested in your work, or
how you have been affected by treating people with
mental illnesses. When you finish sharing, turn to
the next group member and ask:

How has it been for you? How has mental illness
affected your life?

After group members have each briefly shared
a story, thank them. Point out any similarities
to another group member’s experiences.

Save 5 minutes to socialize before ending the
session. Prompt discussions on concrete topics
such as weekend or holiday plans. The purpose
of socializing is to stimulate and encourage
interpersonal connections. Socializing promotes
developing social support networks. At the end
of the session also remind group members of the
time and date of the next session.

Try some tips for common difficulties

During this session, it may be difficult for group
members to confide their problems. Offer plenty
of support and validation to encourage people to
talk. Be careful to respect personal boundaries by
conveying that group members can say as much or
as little as they wish. Ask questions to keep reluctant
group members talking and to promote connections
such as similar problems, worries, or stories.

This group session may be the first time some group
members realize that they are not alone. Encourage
them to express any feelings that surface while
discussing these difficult experiences. For example,
feelings that families commonly have but are
reluctant to talk about include anxiety, confusion,
fear, guilt, sadness, and grief. Compared to the first
meeting, the mood of this session may be sad.

Sometimes group members express their
unhappiness with the mental health system,
the agency, or a member of the treatment team.
Validate these feelings and experiences and ask
for specific details. But be careful not to let a
specific problem dominate the session.

Group members who have had an opportunity to
discuss their experiences during joining sessions
will be less likely to focus on these issues during

Module 1 6 Basic Elements and Practice PrinciplesModule 4 6 Ongoing Family Psychoeducation Sessions

group sessions. For this reason, we recommend
that you complete all three joining sessions with
consumers and families before introducing the next
phases of the FPE program.

If group members start to talk about specific
problems they want to solve immediately, help
them return to the agenda by saying:

During the next session, we will begin to look
at specific problems and work together to find
solutions. Right now, let’s give [name] a chance
to share with us how mental illness has affected
her life.

Depending on the situation, you may also suggest
meeting outside the group to discuss the problem.

Other difficulties that you may encounter during
group sessions include people having side
conversations, interrupting, monopolizing, or
speaking for others. Address these issues with
positive redirecting remarks, such as:

That’s interesting; I wonder if Mr. Smith has
something to say about this.

Your wife says she thinks you’re over the flu.
How long were you sick?

Understand the importance of humor

Early on, it helps to introduce humor into the
group dynamic. Let group members know that
it is acceptable to have fun and laugh. Model
this behavior as well, when appropriate.

Ongoing multigroup sessions

Many consumers and families have expressed
dissatisfaction with traditional group therapy
models because of the high degree of emotion and
low degree of productivity. FPE responds to these
concerns by offering a clear agenda for each session
and a structured problem-solving approach to help
consumers and families make gains in working
toward personal recovery goals.

Follow the session agenda

Beginning with the third session, the agenda
for multifamily group sessions is as follows:

Multifamily Group Session Agenda

Socialize 15 minutes

Go-around—identify current
issues

20 minutes

Select a single problem 5 minutes

Use structured problem-solving 45 minutes

Socialize 5 minutes

Total 90 minutes

As in the first two sessions, two FPE practitioners
continue to co-facilitate the group. One FPE
practitioner acts as the primary facilitator and
leads the group through the agenda and structured
problem-solving. The other serves as co-facilitator
and ensures group participation, monitors the
overall process, and records the problem-
solving process.

Record the proceedings on a blackboard, flipchart,
or chalkboard. At the end of the session, document
the session on a Progress Note that you can put in
consumers’ charts. Give consumers and families
a copy to take home.

Ongoing Family Psychoeducation Sessions 7 Module 4

Similar to the first and second group sessions,
socialize at the beginning and end of each
group session. Give consumers and families the
opportunity to recapture and practice any social
skills they may have lost due to isolation or
exposure to high levels of stress.

After socializing, begin the go-around to identify
current issues related to mental illness that
consumers and families are managing. It is often
helpful to prompt the go-around discussion by
writing this question at the top of a blackboard:

How have you been affected by the illness since
we last met?

Prompts such as these help group members focus
on the purpose of the go-around. This is also the
time to follow up on consumers’ progress toward
their goals or on their action plan. As each group
member checks in, have your co-facilitator list
the current issues on the blackboard.

Discuss each issue individually. Do not point out
similarities between the concerns of group members
because doing so causes group members to express
problems in more general terms. Instead, for the
purposes of problem-solving, encourage group
members to use their own words to describe their
current issues in detail. This will provide a clearer
and more accurate picture of the issues.

Once you have completed the go-around, review
each issue. Remember to recognize any progress
that consumers have made in achieving steps
toward their goals. If any issues can be readily
solved, offer direct assistance or advice based
on the family guidelines.

Many issues that consumers and families identify
will be too complex to easily resolve. Instead,
choose one for the group to work on during the
session. Ask consumers and families for their
permission to focus on the issue as the group’s
topic. If agreed, discuss this problem for the
remainder of the session.

Use structured problem-solving

Structured problem-solving is a six-step approach
that helps break problems down into a manageable
form so that solutions can be implemented in small,
easy-to-follow steps. Experiencing success in small
steps gives consumers and families hope that
change is possible. Often a small success will
motivate consumers to apply the method to other
aspects of their lives.

 

Six Steps of Structured Problem-
Solving

n Define the problem.

n Generate solutions.

n Discuss advantages and disadvantages
of each solution.

n Choose the best solution.

n Form an action plan.

n Review the action plan.

Select the problem

The first step of the structured problem-solving
approach is to select one problem from the list of
current issues and define it in detail. Selecting and
defining the problem, while sometimes viewed as a
rather simple process, is often the most difficult
step. If the problem is not properly defined,
consumers, families, and practitioners become
frustrated and convinced that it cannot be solved.

Some common difficulties that groups experience
are the following:

n Choosing a problem that is too large or too
general (for example, “I want to get a job”);

n Not reaching consensus on how to define the
problem; and

n Phrasing the problem inaccurately.

Module 1 8 Basic Elements and Practice PrinciplesModule 4 8 Ongoing Family Psychoeducation Sessions

Tell group members that the problem definition
stage can be challenging. Acknowledging that
the process is not simple may alleviate some
frustration later.

To select a problem for the group to discuss, review
the list and consider the scale of the problems
identified. For initial sessions, select simpler
problems so that the group members learn the
structured problem-solving approach, gain trust
in one another, and achieve a few successes. Only
address long-standing or previously intractable
problems if you can break them down into more
solvable subproblems.

Share your reasoning for selecting specific problems.
Thinking aloud while selecting a problem helps

group members learn how to simplify, clarify,
and prioritize concerns.

Once you have selected a problem and the
consumer and family have agreed that the issue
can be the focus of the group session, emphasize
that the goal is to teach the problem-solving
approach and that, with practice, group members
may begin to use the approach outside the group.
It is also important to say:

Although the problem may not currently be a
problem in your life, it is likely that many of you
have faced or will face a similar issue. Hopefully,
we can share our experiences and together find
some possible solutions. Remember if your issue
isn’t the focus for this session, over the course
of the group, we will address everyone’s issues.

Ongoing Family Psychoeducation Sessions 9 Module 4

Evaluate Common Problems

Safety issues Safety is always of primary importance. As you review the issues, address any potential
threats to safety.

Clarify the issue. If the issue is too emotionally charged or is likely to disrupt the group
process, address the issue apart from the group, and update the group about how it
was resolved. Discuss your reasons and plans in as much detail as possible so that group
members have the best possible learning experience.

If the issue is not too emotionally charged or disruptive and can be broken down into
manageable parts, ask the consumer if you may select the problem for the group
to discuss.

Managing symptoms,
substance use, and
medication issues

Reports of actual or potential exacerbation of symptoms are common problems that
you may address in the group. Issues about medications and substance use are also
important. Because these are potentially emotional issues, present or reframe the
problem in nonblaming terms. Blaming consumers or families is not constructive or
helpful. Modeling a nonjudgmental, nonblaming approach often can be a good learning
opportunity for group members.

Life events Sometimes, major events occur (for example, divorce, death, marriage, graduation,
a birth), that can be unsettling for the whole family and especially for someone with
mental illness. It is natural for stress levels to rise at such times, even with positive stress.

Changes sometimes occur within mental health agencies, such as a move to another
building or a practitioner’s resignation that may be as distressing to consumers and
families as other major life events. You may be able to address these issues in the group.

Disagreement
among consumers
and family members

It is natural for consumers and family members to disagree at times. When exploring
issues such as these, consider the following:

The intensity of the disagreement

Sometimes an issue surrounded by intense disagreement is better resolved in single-
family sessions. In such a case, suggest an outside meeting to help with the problem.
If the disagreement does not seem extreme and is selected for problem-solving, keep
criticism and emotions to a minimum. Consider reviewing the Family Guidelines
outlined in Module 3.

Whether the disagreement is a consequence of the mental illness

If the disagreement is a consequence of the mental illness, problem-solving in the
group can be helpful and elicit solutions that are pragmatic and stress-reducing.
However, when a consumer and family member are disagreeing, it may be difficult to
agree on the definition of the problem. One approach is to define the problem broadly,
such as: How can the Smith family manage their disagreement so that John will not be
overwhelmed and relapse?

Module 1 10 Basic Elements and Practice PrinciplesModule 4 10 Ongoing Family Psychoeducation Sessions

Define the problem

The next step is to ask consumers and families
for more information to help the group clearly
understand and define the problem. Ask detailed
questions such as the following:

n What is the current issue?

n When did you first notice the problem?

n When does it occur? How often?
In what situations?

n Has the problem changed in any way recently?

n Whom does the problem affect? How?

n With what activities does the problem interfere?

n What have you tried to alleviate the problem?
What were the results?

n Who seems to have the most impact on the
problem?

Seek consensus on the definition of the problem
by summarizing it in a single sentence or phrase
and asking consumers and families if the definition
makes sense to them. Make sure that you accurately
define the problem. Incorrectly phrasing the
problem can cause the group to generate
ineffective solutions. For example, consumers
or family members may indicate that the person
is the problem. Remember, the problem is the
problem; the person is never the problem.

Once a problem has been defined in a way that is
acceptable to each member of the family, write it
on the blackboard.

Generate solutions

Once you define the problem, ask group members
to offer whatever solution they think may help.
Do not evaluate solutions now since doing so
dramatically reduces the number of solutions
people present. It is often helpful to say:

We know it is difficult to resist discussing suggestions
as people generate them. However, we have found
that by discussing them as we go, some solutions
are left unspoken. Therefore, let’s delay evaluating
solutions until after all suggestions have been made.

The goal is to generate as many ideas as possible
about solving the problem. The more solutions
generated, the more likely one will adequately
address the problem. For this reason, ask all
group members to contribute at least one solution.
Take all ideas seriously and write them on the
blackboard, even if a suggestion seems wild or silly.
It is important that group members feel their ideas
are respected and no idea is discounted.

Discuss advantages and disadvantages
of each solution

After people have presented all their solutions,
invite group members to weigh the advantages
and disadvantages of each. On the blackboard,
simply write a plus [+] next to the solution when
someone identifies an advantage and a minus [-]
after the solution when someone identifies a
disadvantage. When possible, take time to evaluate
the solutions as a group. When time is short, some
facilitators streamline the evaluation process by
presenting the solutions to the group to review
and select. Unfortunately, when this process is
shortchanged, consumers do not fully benefit from
the others’ experiences.

Choose the best solution

When you evaluate all solutions, review the list
emphasizing solutions that have the most advantages
and fewest disadvantages. Then ask consumers
which solutions they would like to test for
themselves over the next 2 weeks. Stress that testing
solutions is for the benefit of everyone in the group
because everyone is looking for solutions that work.

Ongoing Family Psychoeducation Sessions 11 Module 4

Form an action plan

Once you select a solution, develop a detailed
action plan. Typically, you will break the solution
down into small steps or tasks. Specify each step
by asking:

n What needs to happen first?

n Who will do that step?

n When will that step happen?

n Where will people meet for that step?

Discuss each step or task and assign someone
responsibility for completing it by a specific date.
Some plans include tasks that all group members
may try. Others are designed specifically for the
consumer and family who presented the problem.

Once you develop the action plan, have your co-
facilitator record the steps on a Progress Note form.
Make copies for the consumer’s chart and for the
consumer and family.

Review the action plan

When appropriate, tell the consumer and family
that you may check on their progress during the
coming week and that you are available for help.
Remind them that the group will look forward
to an update during the next session.

At the beginning of the next session (during the go-
around), review the action plan and followup on the
consumer’s progress. Ask:

n What steps were completed?

n What went well?

n What did not go so well?

Praise all efforts and point out any progress.
If steps were not completed, explore obstacles
and alternatives. If consumers encountered
significant challenges that cannot be resolved
quickly, suggest meeting individually with the
consumer and family outside the group to explore
the issue in greater detail. When possible, update
the group about the outcome to ensure that others
can learn from the experience.

Module 1 12 Basic Elements and Practice PrinciplesModule 4 12 Ongoing Family Psychoeducation Sessions

Difficulties encountered

At any point during the group, if consumers or
families who have identified the problem begin
to struggle with the process, make sure you have
accurately defined the problem and that the group
is addressing the true problem. It is better to stop
the process and clarify the problem definition than
to generate solutions that are irrelevant to the current
issues that consumers and families are facing.

Many issues that the group presents are perceived
as unsolvable. These are often long-standing
problems that have resisted all attempts to make
them better. Group members seldom have much
hope that things will change. With this in mind,
collect as much information as possible when you
select and define problems so that you may break
large problems down into smaller parts and work
on them incrementally. When things do change,
acknowledge the efforts of those involved in
the change.

In some instances, stray from the
structured problem-solving approach

Use the problem-solving approach for most
multifamily group sessions. However, occasionally
group members may identify issues that are best
addressed with a different approach. In this case,
alter the approach by bringing in guest speakers
or by offering specific skills training. For example,
research shows that interspersing skills training
targeted to the symptoms of obsessive-compulsive
disorder is an effective adaptation of FPE for
families and consumers with this illness (Van
Noppen, 1999).

Throughout the FPE program, continue to share
educational materials targeted to specific mental
illnesses in different formats (for example, video,
print, and website resources). Remaining responsive
to the needs of consumers and families will keep
them engaged in FPE services.

When needed, offer ongoing
Family Psychoeducation services
in a single-family format

You can easily adapt the goals of ongoing
multifamily sessions to the single-family format.
Introduce consumers and families to the structured
problem-solving approach and work with them
to identify current issues that may be addressed
collaboratively. Follow the guidelines described
in the multifamily group format.

While consumers and families will not have the
benefit of other group members’ experiences, it
is still possible to identify strengths, resources,
and strategies that have worked in the past. With
consumers and families, generate solutions and
evaluate each one to select the best choice. Next,
collaborate with the consumer and family to
develop a detailed action plan.

Tailor single-family sessions to the needs of the
consumer and family. Keep your work with
consumers and families task oriented and focused
on consumers’ personal recovery goals. For more
resources on the single-family format, see The
Evidence in this KIT.

Ongoing Family Psychoeducation Sessions 13 Module 4

Exercise: Practice What You’ve Learned About Multifamily Groups

n  Role play: Conduct a role play to practice introducing the format of the first two multifamily group
sessions. Practice how you may introduce yourself during the first group session.

n  Group discussion: Discuss as a group how you would redirect a consumer or family member who becomes
upset during the second multifamily group session.

Ongoing Family Psychoeducation Sessions 15 Module 4

Exercise: Review the Progress Note for Ongoing Family Psychoeducation Sessions

Distribute a copy of your agency’s Progress Note for ongoing FPE sessions. Review the components of this
form and discuss as a group.

Problem Solutions from Actual Practice 17

Module 5

Module 5

Problem Solutions from Actual Practice
Notes to the family intervention coordinator

Prepare for Module 5:

n Make copies of Module 5. Your copy
is in this workbook; print additional
copies from the CD-ROM in the KIT.

n Distribute the material to those who are
participating in your group training. Ask
them to read it before the group training.

n  Make copies of the following
exercise:

o Practice What You’ve Learned
About Problem-Solving

Do not distribute them until the group
training. Your copies are in this workbook;
print additional copies from the CD-ROM
in the KIT.

Conduct your fifth training session:

n Discuss the content of Module 5.

n Distribute the exercise and complete
it as a group.

Note: This module has no corresponding Practice
Demonstration Video component.

Problem Solutions from Actual Practice 1 Module 5

Training Frontline Staff

Module 5: Problem Solutions from Actual Practice

Module 5 presents case studies of actual multifamily groups and catalogues a
variety of responses to two commonly presented issues: finding or keeping a job
and using medications. Although these examples capture problems and solutions
that have emerged from real groups, they also apply to single-family sessions.

Overview of the module

Every group is unique. One approach will
not solve all difficulties that consumers and
families face. To be successful, solutions
must be relevant and acceptable to
consumers and families. This module
presents the experiences of those who have
participated in FPE programs. We selected
two areas—employment-related and
medication-related issues—because
they are commonly raised and especially
challenging. Also, they are a frequent
source of tension and conflict for
consumers, families, and practitioners.

Disagreements can be destabilizing or,
at least, can prevent rehabilitation if left
unresolved. Rather than trying to resolve
disagreements directly, the structured
problem-solving approach allows
practitioners, consumers, and families
to alleviate the effects of conflicts by
finding alternative paths or identifying
common ground.

Module 5 2 Problem Solutions from Actual Practice

Employment issues

This section begins with two case studies that show
you how the problem-solving approach has been
used to define and address employment-related
issues. It also presents a log of similar problems
and solutions identified through FPE multifamily
groups. In some cases, staff from evidence-based
practice Supported Employment programs have
co-facilitated these groups.

Pedro’s story

Pedro, a man in his mid-30s, has struggled with
serious mental illnesses since his late teens. He has
been able to maintain an apartment and stay on
medication for years with minimal support, but
until recently had been unemployed. He is working
closely with an employment specialist to make his
part-time job successful, but shares some concerns
with the multifamily group.

Step 1 Define the problem

In Step 1, the goal is to narrow the definition of the
problem so that the group can generate practical,
concrete solutions. To better understand Pedro’s
concerns, the facilitator asked him to talk about his
typical workday. Next, the facilitator asked Pedro’s
sister more questions to understand her perspective.
This process revealed that, since Pedro had not had
much work experience, he was uncomfortable with
co-workers.

The facilitator defined the problem as:

How can Pedro become more comfortable with his
co-workers?

Pedro and his sister agreed with the definition of
the problem and the co-facilitator wrote it on the
blackboard.

Step 2 Generate solutions

All members of the group brainstormed and
generated the following list:

n Tell yourself there’s no pressure to be friends
with everyone.

n Ask for support.

n Connect with people who do the same job.

n Do the best job you can.

n Plan activities outside of work.

n Make small talk.

n Compliment people.

n Give yourself credit.

n Use humor.

n Join work-related activities such as lunch.

n Bring in food to share.

n Ask questions to get to know others.

Step 3 Discuss advantages and disadvantages

The facilitator read each solution aloud and asked
group members:

What are the main advantages of this solution?

After the co-facilitator recorded the advantages,
the facilitator asked, “What are the disadvantages
of this solution?” The co-facilitator wrote all
responses on the blackboard.

Step 4 Choose the best solution

The facilitator reviewed the solutions for which the
disadvantages outweighed the advantages. In these
cases, the group agreed to cross out these solutions.
Of the remaining solutions, the facilitator asked
Pedro which he would like to try. Pedro chose the
following solutions; his sister agreed that they are
good ones to try:

n Join a work-related activity; and

n Bring in food to share.

Problem Solutions from Actual Practice 3 Module 5

Step 5 Form an action plan

The group helped Pedro break the solutions
that he chose down into manageable, concrete,
specific steps.

 

Pedro’s Action Plan

n Set aside grocery money.

n Make a shopping list.

n Shop for apricot bread ingredients during
the week.

n Bake bread on Saturday afternoon.

n Bring bread to work on Sunday.

n Join co-workers for lunch on Sunday.

Step 6 Review the action plan

In the go-round of the next group meeting, the
facilitator asked Pedro about his experience in
working on his action plan. The group learned that
Pedro set aside the grocery money, made a shopping
list, and bought the ingredients for apricot bread.
Unfortunately, he burned the bread and was unable
to bake a second loaf before work on Sunday.

Although he didn’t have any bread to share, he
did join his co-workers for lunch. He shared his
breadmaking story and his co-workers laughed.
He reported that it helped break the ice and he felt
more comfortable with his co-workers. Facilitators
and group members praised his courage and efforts.

Module 5 4 Problem Solutions from Actual Practice

Sharon’s story

Sharon is a 38-year-old woman with a schizoaffective
disorder. She lives alone with her cat and works
part-time (every morning for 4 hours) in the
mailroom of a large insurance company. The bus
stop to work is within easy walking distance of her
apartment. She likes the routine of working every
day and has become quite efficient at her job, which
does not vary too much from day to day. Recently,
however, some of her work duties have changed.

Step 1 Define the problem

The facilitator asked Sharon to explain how her
work has changed. Sharon explained that the
company is handling bulk mailings that must go out
quickly, increasing tension at the worksite. Sharon
told the group that she found the fast pace difficult
and stressful. The facilitator defined the problem as:

What can Sharon do to feel less overwhelmed at
work when bulk mailings must go out quickly?

Sharon and her parents agreed with the problem
definition and the co-facilitator wrote it on the
blackboard.

Step 2 Generate solutions

The facilitator asked group members for possible
solutions. They generated the following list:

n Quit.

n Talk to the supervisor.

n Set limits for yourself.

n Take more frequent breaks.

n Go to the gym to relieve tension.

n Get a massage.

n Reduce your hours at those times.

n Scream into a pillow.

n Practice stress reduction techniques.

n Seek peer support.

Step 3 Discuss advantages and disadvantages

The group discussed the advantages of each
suggestion first, then the disadvantages. The co-
facilitator wrote all responses on the blackboard.

Step 4 Choose the best solution

After reviewing the advantages and disadvantages,
the group eliminated several solutions. Sharon
chose the following solutions; her parents agreed
they are good ones to try:

n Talk to your supervisor.

n Practice stress reduction techniques.
Step 5 Form an action plan

With the group’s help, Sharon and her parents
developed the following action plan:

n Approach the supervisor first thing in the
morning to ask for a meeting time.

n Meet with the supervisor.

n Use stress reduction techniques before and after
work for 1 week.

Then they conducted a role play in the group so
Sharon could practice what she wants to say to her
supervisor. Next, the facilitator introduced a stress
reduction technique. All group members practiced
the technique once together.

Step 6 Review the action plan

At the next group session, Sharon reported that
she had not approached her supervisor during
the previous 2 weeks. She practiced her stress
reduction technique, which she liked. Although
work was still tense sometimes, she reported that
she feels better about it.

Problem Solutions from Actual Practice 5 Module 5

The following log outlines other employment-related problems and solutions that FPE multifamily
groups identified.

Log of Other Employment-Related Problems and Solutions

Problem Possible solutions

Finding work n Look through want ads.

n Walk or drive around the community in search of job openings.

n Talk with members of your social support network.

n Use the yellow pages to identify jobs of interest.

n Visit jobs of interest.

n Enroll in a Supported Employment program.

Adjusting to a new job n Prepare for your first day (set an alarm clock, pack lunch, practice a bus route).

n Ask questions, as needed, about the job.

n Review your written job description.

n Arrive early to get comfortable with the place.

n Take one day at a time.

n Work with an employment specialist.

Managing symptoms
and stress at work

n If symptoms affect your concentration, make notes to remember tasks or instructions.

n Ask for an accommodation such as a quiet workspace or regular breaks.

n Use stress reduction strategies.

n Identify a buddy at work with whom you can talk.

n Carry PRN medication.

n Work with an employment specialist.

Module 5 6 Problem Solutions from Actual Practice

Medication issues

The following case study shows you how the
problem-solving approach has been used to define
and address medication issues. This section also
presents a log of other medication-related problems
and solutions identified through FPE multifamily
groups. In some cases, a psychiatrist or nurse co-
facilitated these groups.

Darcy’s story

Darcy is a 29-year-old woman who has
schizoaffective disorder. She is the mother of two
young children. It is important to her to function
well enough to care for her family, as well as to
take one course each semester as she works toward
her undergraduate degree. Following the advice
of her doctor, Darcy recently started taking a new
medication.

Step 1 Define the problem

The facilitator asked Darcy to explain the concerns
that she had about the new medication she is taking.
Darcy explained that the medication makes her feel
tired. She was unable to concentrate in class and
frequently nodded off.

The facilitator defined the problem as:

What can Darcy do if she’s experiencing side effects
from her medication?

Darcy and her family agreed with the problem
definition and the co-facilitator wrote it on
the blackboard.

Step 2 Generate solutions

The facilitator asked all group members to
contribute possible solutions. The group generated
the following solutions:

n Call the doctor.

n Cut down on the medication.

n Ask someone to take notes in class.

n Bring a tape recorder to class.

n Drink coffee.

n Ask a classmate to wake her.

Step 3 Discuss advantages and disadvantages
The group discussed the advantages of each
suggestion first, then the disadvantages. The co-
facilitator wrote all responses on the blackboard.
Step 4 Choose the best solution

After reviewing the advantages and disadvantages,
the group eliminated several solutions. Darcy chose
the following solutions; her family members agreed
they are good ones to try:

n Bring a tape recorder to class.
n Call the doctor.
Step 5 Form an action plan

With the group’s help, Darcy and her family
developed the following action plan:

n After class on Wednesday, Darcy will set up an
appointment with her professor. She will tell her
professor that she is sleepy in class because of the
side effects of a medication and she will ask if she
can record the class until her dose is corrected.

n Tomorrow morning, Darcy will call to set up
an appointment with her doctor. Her family
member agrees to go with her to the appointment
for support.

Problem Solutions from Actual Practice 7 Module 5

Step 6 Review the action plan

One week later, the facilitator called Darcy to see
how she is doing and if she needed any help with
the action plan. Darcy reported that she had set up
her appointments. They reviewed what she wished
to say during each meeting.

At the next group session, Darcy reported that she
received permission to tape record her class. She

still fell asleep twice last week but her doctor
suggested taking her medication at night and that
seems to help. Her doctor agreed that she should
lower the dose of her medication if the side effects
continue for another 2 weeks.

The following log outlines other medication-related
problems and solutions that FPE multifamily
groups identified.

Log of Other Medication-Related Problems and Solutions

Problem Possible solutions

Forgetting to take
medications

n Take medications at the same time every day.

n Set a timer.

n Combine taking medications with another daily activity such as brushing your teeth.

n Ask a buddy to call and remind you.

n Leave yourself a note.

Difficult medication
regimes

n Talk with your doctor to see if your medication schedule can be simplified.

n Write a schedule on your calendar.

n Keep a medication record.

n Use a pill container. Ask a buddy for help.

Communicating
medication issues
to your doctor

n Ask for a longer appointment time.

n Role-play how you would present your concerns to your doctor.

n Ask other treatment team members to speak to your doctor with you.

n Ask a family member to join you for your appointment.

n Write down your concerns or keep a medication record and share it with your doctor.

Many concerns that consumers raise about
medications may be viewed as decisional conflicts.
In other words, consumers may feel conflicted
about their decision to take medication as
prescribed. The structured problem-solving
approach is an effective way to address such
concerns as long as consumers agree with the way

that the problem is defined and actively participate
in weighing the advantages and disadvantages of
the solutions generated. It is important to create
an environment in which all group members feel
comfortable voicing their ideas and consumers feel
supported in weighing the options and choosing the
best solution.

Problem Solutions from Actual Practice 9 Module 5

Exercise: Practice What You’ve Learned About Problem Solving

Select three members of your training group to play the roles of practitioner, consumer, and family member.
Conduct role plays to practice using the structured problem-solving approach in either a single-family or
multifamily group format.

n  Conduct a role play to address an issue related to employment.

n  Conduct a role play to address an issue related to medication.

HHS Publication No. SMA-09-4422
Printed 2009

26171.0709.7765020404

Cover
• Title Page

Acknowledgments
Training Frontline Staff

• What’s in Training Frontline Staff
• Training Frontline Staff How Family Intervention Coordinators Should Use This Workbook

Prepare program-specific information
Prepare agency-specific information
Visit an existing team
Arrange for didactic training
Recruit a consultant
Cross-train
For more information

• Module 1: Basic Elements and Practice Principals

What is Family Psychoeducation?
The phases of Family Psychoeducation
Practice principles
The family experience
Core values in Family Psychoeducation
Program standards
How we know that Family Psychoeducation is effective
Adapting the evidence-based model
Summary
Exercise: Explore the Benefits of Family Psychoeducation
Exercise: Examine Program Standards

• Module 2: The Core Processes of Family Psychoeducation

Identify consumers
Introduce the program
Conduct joining sessions
Conduct the educational workshop
Offer ongoing Family Psychoeducation services
Engage consumers and families continuously
Complete Progress Notes
Participate in supervision
Summary
Exercise: Identify Consumers and Families
Exercise: Introduce Your Program

• Module 3: Joining Sessions and Educational Workshops

Joining sessions
Educational workshops
Exercise: Review Progress Notes for Joining Sessions and Educational Workshops
Exercise: Practice What You’ve Learned About Joining Sessions
Module 4: Ongoing Family Psychoeducation Sessions
Conduct ongoing Family Psychoeducation sessions
Structure of multifamily groups
Overview of the first session
Overview of the second session
Ongoing multigroup sessions
Exercise: Practice What You’ve Learned About Multifamily Groups
Exercise: Review the Progress Note for Ongoing Family Psychoeducation Sessions
Module 5: Problem Solutions from Actual Practice
Overview of the module
Employment issues
Medication issues
Exercise: Practice What You’ve Learned About Problem Solving

TheEvidence

Family

Psychoeducation

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

http://www.samhsa.gov

Family
Psychoeducation

The
Evidence

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

Acknowledgments

This document was prepared for the Substance Abuse and Mental Health Services Administration
(SAMHSA), U.S. Department of Health and Human Services (HHS) under contract numbers
280-00-8049 with the New Hampshire-Dartmouth Psychiatric Research Center and 270-03-6005
with Westat. Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served as SAMHSA Government
Project Officers.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors and
do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services
(CMHS), SAMHSA, or HHS.

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced
or copied without permission from SAMHSA. Citation of the source is appreciated. However,
this publication may not be reproduced or distributed for a fee without the specific, written
authorization from the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, please
call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English
and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Family Psychoeducation: The
Evidence. HHS Pub. No. SMA-09-4422, Rockville, MD: Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration, U.S. Department of Health
and Human Services, 2009.

Originating Office

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
Rockville, MD 20857

HHS Publication No. SMA-09-4422
Printed 2009

http://www.samhsa.gov/shin

Family
Psychoeducation

The Evidence

The Evidence introduces all stakeholders to the research literature
and other resources on Family Psychoeducation (FPE). This booklet
includes the following:

  A review of the FPE research literature;

  A selected bibliography for further reading;

 

References

for the citations presented throughout the KIT; and

  Acknowledgements of KIT developers and contributors.

This KIT is part of a series of Evidence-Based Practices KITs created
by the Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration, U.S. Department of Health
and Human Services.

This booklet is part of the Family Psychoeducation KIT that includes
a DVD, CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Staff

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP

Family
Psychoeducation

What’s in The Evidence

Review of Research Literature

. . . . . . . . . . . . . . . . . . . . 1

Selected Bibliography

. . . . . . . . . . . . . . . . . . . . . . . . 11

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

The Evidence 1 Review of Research Literature

The Evidence

Review of the Research Literature

A number of research articles summarize
the effectiveness of Family
Psychoeducation (FPE). This KIT includes
a full text copy of one of them:

Dixon, L., McFarlane, W. R., Lefley, H.,
Lucksted, A., Cohen, M., Falloon, I.,
et al. (2001). Evidence-based practices
for services to families of people with
psychiatric disabilities. Psychiatric
Services, 52, 903-910.

This article describes the critical
components of the evidence-based model
and its effectiveness. Barriers to
implementation and strategies for
overcoming them are also discussed, based
on experiences in several states.

This article may be viewed or printed from
the CD-ROM in your KIT. For a printed
copy, see page 3.

The Evidence 3 Review of Research Literature

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Evidence-Based Practices for
Services to Families of People
With Psychiatric Disabilities

2001
Dedicated to

Evidence

–

Based

Psychiatry

Lisa Dixon, M.D., M.P.H.
William R. McFarlane, M.D.
Harriet Lefley, Ph.D.
Alicia Lucksted, Ph.D.
Michael Cohen, M.A.
Ian Falloon, M.D.
Kim Mueser, Ph.D.
David Miklowitz, Ph.D.
Phyllis Solomon, Ph.D.
Diane Sondheimer, M.S., M.P.H.

Family psychoeducation is an evidence-based practice that has been
shown to reduce relapse rates and facilitate recovery of persons who
have mental illness. A core set of characteristics of effective family
psychoeducation programs has been developed, including the provi-
sion of emotional support, education, resources during periods of cri-
sis, and problem-solving skills. Unfortunately, the use of family psy-
choeducation in routine practice has been limited. Barriers at the lev-
el of the consumer and his or her family members, the clinician and
the administrator, and the mental health authority reflect the exis-
tence of attitudinal, knowledge-based, practical, and systemic obsta-
cles to implementation. Family psychoeducation dissemination efforts
that have been successful to date have built consensus at all levels, in-
cluding among consumers and their family members; have provided
ample training, technical assistance, and supervision to clinical staff;
and have maintained a long-term perspective. (Psychiatric Services
52:903–910, 2001)

Dr. Dixon and Dr. Lucksted are affiliated with the Center for Mental Health Services
Research at the University of Maryland School of Medicine in Baltimore and with the De-
partment of Veterans Affairs Capitol Health Care Network Mental Illness Research, Ed-
ucation, and Clinical Center, 701 West Pratt Street, Room 476, Baltimore, Maryland
21201 (e-mail, ldixon@umaryland.edu). Dr. McFarlane is affiliated with the Maine
Medical Center in Portland. Dr. Lefley is with the University of Miami School of Medi-
cine. Mr. Cohen is with the New Hampshire chapter of the National Alliance for the
Mentally Ill in Concord. Dr. Falloon is with the University of Auckland in Auckland,
New Zealand. Dr. Mueser is with Dartmouth Medical School in Hanover, New Hamp-
shire. Dr. Miklowitz is with the University of Colorado. Dr. Solomon is with the Uni-
versity of Pennsylvania School of Social Work in Philadelphia. Ms. Sondheimer is with
the Child, Adolescent, and Family Branch of the Center for Mental Health Services in
Rockville, Maryland.

Family members and other persons involved in the lives and care of adults who have
serious mental illnesses often pro-
vide emotional support, case man-
agement, financial assistance, advo-
cacy, and housing to their mentally ill
loved ones. Although serving in this
capacity can be rewarding, it impos-
es considerable burdens (1–4). Fam-
ily members often have limited ac-
cess to the resources and informa-
tion they need (5–7). Research con-
ducted over the past decade has
shown that patients’ outcomes im-
prove when the needs of family
members for information, clinical
guidance, and support are met. This
research supports the development
of evidence-based practice guide-
lines for addressing the needs of
family members.

Several models have evolved to ad-
dress the needs of families of per-
sons with mental illness: individual
consultation and family psychoedu-
cation conducted by a mental health
professional (8,9), various forms of
more traditional family therapy (10),
and a range of professionally led
short-term family education pro-
grams (11,12), sometimes referred
to as therapeutic education. Also
available are family-led information

PSYCHIATRIC SERVICES ♦ July 2001 Vol. 52 No. 7

903

mailto:ldixon@umaryland.edu

Review of Research Literature 4 The Evidence

and support classes or groups, such
as those provided by the National Al-
liance for the Mentally Ill (NAMI)
(13,14). Family psychoeducation has
a deep enough research and dissem-
ination base to be considered an evi-
denced-based practice. However,
the term “psychoeducation” can be
misleading: family

psychoeducation

includes many therapeutic elements,
often uses a consultative framework,
and shares characteristics with other
types of family interventions.

In general, evidence-based prac-
tices are clinical practices for which
scientific evidence of improvement
in consumer outcomes has been con-
sistent (15). The scientific evidence
of the highest standard is the ran-
domized clinical trial. Often, several
clinical trials are pooled by use of a
technique such as meta-analysis to
identify evidence-based practices.
Quasi-experimental studies, and to a
lesser extent open clinical trials, can
also be used. However, the research
evidence for an evidence-based
practice must be consistent and suf-
ficiently specific for the quality and
outcome of the intervention to be
assessed.

The purpose of this article, as part
of a larger series on evidenced-based
practices for persons with severe
mental illnesses (15), is to describe
family psychoeducation, the basis for
its identification as an evidence-based
practice, and barriers to its imple-
mentation. We also propose strategies
for overcoming these barriers.

What is family psychoeducation?
A variety of family psychoeducation
programs have been developed by
mental health care professionals
over the past two decades (8,9).
These programs have been offered
as part of an overall clinical treat-
ment plan for individuals who have
mental illness. They last nine months
to five years, are usually diagnosis
specific, and focus primarily on con-
sumer outcomes, although the well-
being of the family is an essential in-
termediate outcome. Family psy-
choeducation models differ in their
format—for example, multiple-fami-
ly, single-family, or mixed sessions—
the duration of treatment, consumer
participation, location—for example,

clinic based, home, family practice,
or other community settings—and
the degree of emphasis on didactic,
cognitive-behavioral, and systemic
techniques.

Although the existing models of
family intervention appear to differ
from one another, a strong consen-
sus about the critical elements of
family intervention emerged in 1999
under the encouragement of the
leaders of the World Schizophrenia
Fellowship (16).

Goals and principles
for working with families
The main goals in working with the
family of a person who has a mental
illness are to achieve the best possible
outcome for the patient through col-
laborative treatment and manage-
ment and to alleviate the suffering of
the family members by supporting
them in their efforts to aid the recov-
ery of their loved one.

Treatment models that have been
supported by evidence of effective-
ness have required clinicians to ad-
here to 15 principles in working with
families of persons who have mental
illness:

♦ Coordinate all elements of treat
ment and rehabilitation to ensure that
everyone is working toward the same
goals in a collaborative, supportive re-
lationship.

♦ Pay attention to both the social
and the clinical needs of the consumer.

♦ Provide optimum medication
management.

♦ Listen to families’ concerns and
involve them as equal partners in the
planning and delivery of treatment.

♦ Explore family members’ expec-
tations of the treatment program and
expectations for the consumer.
♦ Assess the strengths and limita-

tions of the family’s ability to support
the consumer.

♦ Help resolve family conflict by
responding sensitively to emotional
distress.

♦ Address feelings of loss.
♦ Provide relevant information for

the consumer and his or her family at
appropriate times.

♦ Provide an explicit crisis plan
and professional response.

♦ Help improve communication
among family members.

♦ Provide training for the family in
structured problem-solving techniques.

♦ Encourage family members to
expand their social support net-
works—for example, to participate in
family support organizations such as
NAMI.

♦ Be flexible in meeting the needs
of the family.

♦ Provide the family with easy ac
cess to another professional in the
event that the current work with the
family ceases.

–

Overview of the research
Studies have shown markedly higher
reductions in relapse and rehospital-
ization rates among consumers whose
families received psychoeducation
than among those who received stan-
dard individual services (17–20), with
differences ranging from 20 to 50
percent over two years. For programs
of more than three months’ duration,
the reductions in relapse rates were at
the higher end of this range. In addi-
tion, the well-being of family mem-
bers improved (21), patients’ partici-
pation in vocational rehabilitation in-
creased (22), and the costs of care de-
creased (4,20,23,24).

As a result of this compelling evi-
dence, the Schizophrenia Patient
Outcomes Research Team (PORT)
included family psychoeducation
among its treatment recommenda-
tions. The PORT recommended that
all families who have contact with a
relative who has mental illness be of-
fered a family psychosocial interven-
tion that spans at least nine months
and that includes education about
mental illness, family support, crisis
intervention, and problem solving
(25). Other best-practice standards
(26–28) have recommended that fam-
ilies participate in education and sup-
port programs. In addition, an expert
panel that included clinicians from
various disciplines as well as families,
consumers, and researchers empha-
sized the importance of engaging
family members in the treatment and
rehabilitation of persons who are
mentally ill (29,30).

Delivering the appropriate compo-
nents of family psychoeducation for
patients and their families appears to
be an important determinant of out-
comes for both consumers and their

PSYCHIATRIC SERVICES ♦ July 2001 Vol. 52 No. 7 904

The Evidence 5 Review of Research Literature

families. It has been demonstrated
that programs do not reduce relapse
rates if the information presented is
not accompanied by skills training,
ongoing guidance about management
of mental illness, and emotional sup-
port for family members (31).

In addition, these interventions
that present information in isolation
tend to be brief: a meta-analysis of 16
studies found that family interven-
tions of fewer than ten sessions had
no substantial effects on the burden
of family members (32). However,
the number of sessions could not
completely explain the differences in
outcomes. The outcomes may have
been influenced by the total duration
of treatment rather than the number
of sessions, or by the individual ther-
apist’s approach to dealing with the
emotional reactions of patients and
their families. The behaviors and dis-
ruptions associated with schizophre-
nia, in particular, may require more
than education to ameliorate the bur-
den on the family and enhance con-
sumer outcomes.

Most studies have evaluated family
psychoeducation for schizophrenia or
schizoaffective disorder only. Howev-
er, the results of several controlled
studies support the benefits of both
single- and multiple-family interven-
tions for other psychiatric disorders,
including bipolar disorder (33–38),
major depression (39–41), obsessive-
compulsive disorder (42), anorexia
nervosa (43), and borderline person-
ality disorder (44). Gonzalez and col-
leagues (45) have extended this re-
search to deal with the secondary ef-
fects of chronic physical illness.

Family psychoeducation thus has a
solid research base, and leaders in the
field have reached consensus on the
essential components and techniques
of family psychoeducation. This form
of treatment should continue to be
recommended for use in routine
practice. However, several important
gaps remain in the knowledge re-
quired to make comprehensive evi-
dence-based practice recommenda-
tions and to implement them with a
wide variety of families.

First, although the members of the
World Schizophrenia Fellowship and
others have delineated the core com-
ponents of a successful family inter-

PSYCHIATRIC SERVICES ♦ July 2001 Vol. 52 No. 7 905

vention, the minimum ingredients
are still not clear. This gap was high-
lighted by a study of treatment strate-
gies for schizophrenia, which found
no significant difference in relapse
rates between families who received a
relatively intensive program—a sim-
plified version of cognitive-behavioral
family intervention plus a multiple
family group—and those who re-
ceived a less intensive psychoeduca-
tional, or supportive, multiple-family
group program (46). However, both
programs provided levels of support
and education to families that far sur-
passed those provided by usual serv-
ices. It will be necessary to conduct
studies designed to identify the least
intensive and smallest effective
“dose” of family psychoeducation.

Family
psychoeducation

has a solid research base,

and leaders in the field have

reached consensus on its

essential components

and techniques.

Second, increasing the sophistica-
tion, variety, and scope of indicators
that are used to measure “benefit” is
essential. Commonly used bench-
marks are subject to complicated in-
tervening variables and need to be
correlated with other results. For ex-
ample, a greater number of hospital-
izations for a mentally ill person dur-
ing the year after family psychoedu-
cation could be a positive sign if it in-
dicates that a previously neglected
consumer is getting care and that the
family is getting better at identifying
prodromal symptoms that indicate an
impending relapse (4). The well-be-
ing and health of the family should be
routinely measured as well.

A third knowledge gap involves the
relationship between family psychoe-
ducation and other programs. Since
the conception of family psychoedu-
cation, other psychosocial programs
have developed a substantial eviden-
tiary base, including supported em-
ployment and assertive community
treatment (47,48). For example, as-
sertive community treatment com-
bined with family psychoeducation
has been associated with better non-
competitive employment outcomes
than assertive community treatment
alone (22). The combination of as-
sertive community treatment, family
psychoeducation, and supported em-
ployment has been associated with
better competitive employment out-
comes than conventional vocational
rehabilitation, although the contribu-
tions of each component could not be
assessed in that study (49). The op-
portunities for family psychoeduca-
tion to be combined with or com-
pared with these new psychosocial
models have not been fully explored.

Fourth, research is needed to re-
fine the interventions so that they
better address different types of fam-
ilies, different situations, and differ-
ent time points throughout the course
of illness. For example, there is some
evidence that individualized consulta-
tion may be more beneficial than
group psychoeducation for families
who have existing sources of support
or who already belong to a support
group (50–52).

Fifth, although family psychoedu-
cation has been tested in a wide range
of national and global settings, there
is still a need to assess modifications
in content and outcome among par-
ticular U.S. subcultures and in other
countries. In the United States the
one study involving Latino families
had mixed results (53,54). However,
studies in China (55–57) as well as
studies that are under way among
Vietnamese refugees living in Aus
tralia have had results comparable to
those of studies conducted in Cau-
casian populations.

–

Finally, what happens after a family
has completed a psychoeducation
program? Families of consumers with
long-term problems and disability
may need ongoing support and en-
hanced problem-solving skills to deal

Review of Research Literature 6 The Evidence

with the vicissitudes of illness. Lefley
(58) has described ad hoc psychoedu-
cation in informal settings, such as an
ongoing family support group con-
ducted through a medical center. Mc-
Farlane (4,59) has used a usually
open-ended multiple-family group
structure. NAMI’s Family-to-Family
program is limited to 12 sessions of
formal education but offers continu-
ity in the NAMI support and educa-
tional group structure (14).

Barriers to implementation
Despite the gaps in the research, the
extensive documentation of the basic
benefits of family psychoeducation
prompts the question of why this
service is rarely offered. In general,
low levels of contact between clinical
staff and family members in public
and community-based settings may
preclude the more substantial educa-
tional or support interventions. Also,
the availability of any intervention is
limited by the availability of people to
provide it and the training necessary
to equip those people. The requisite
clinicians, resources, time, and reim-
bursement have not been forthcom-
ing. These deficits imply the exis-
tence of larger obstacles related to at-
titudes, knowledge, practicality, and
systems.

Consumers and family members
Implementation of family psychoedu-
cation may be hindered by realities in
the lives of potential participants.
Practical impediments such as trans-
portation problems and competing
demands for time and energy are
common (50). If family members per-
ceive that the training provided
through family psychoeducation in-
volves expectations of additional care-
giving responsibilities, they may stay
away (16). Sessions must be sched-
uled during periods when facilitators
are available, but these times may not
suit the clients and their families.
Family members face significant bur-
dens that may pose barriers to attend-
ing family psychoeducation sessions,
even though attendance could lighten
these burdens (60,61).

In addition, stigma is common—
family members may not want to be
identified with psychiatric facilities.
They may feel uncomfortable reveal-

ing that there is psychiatric illness in
their family and airing their problems
in a public setting. They may have
had negative experiences in the past
and be hesitant to expose themselves
to the possibility of further negative
experiences. Most people have not
had access to information about the
value of family psychoeducation and
so may not appreciate the potential
utility of these programs (16). They
may believe that nothing will help.
Consumers may have similar appre-
hensions and may worry about losing
the confidential relationship with
their treatment teams or about losing
autonomy.

Clinicians and
program administrators
The lack of availability of family psy-
choeducation may reflect an under-
appreciation on the part of mental
health care providers of the utility
and importance of this treatment ap-
proach (16,18,31,50). Providers may
choose medication over psychosocial
interventions, and family involve-
ment may seem superfluous. In addi-
tion, some providers may still adhere
to theories that blame family dynam-
ics for schizophrenia. Bergmark (62)
noted the persistence of psychody-
namic theories as a potential barrier,
because many families perceive these
theories as blaming. The findings on
expression of emotion—the original
basis for family psychoeducation—
are often perceived similarly despite
researchers’ attempts to avoid imply-
ing blame (16,50).

Although the knowledge and un-
derlying assumptions of individuals
are important, they are only part of
the picture. Wright (63) found that
job and organizational factors were
much better predictors of the fre-
quency of mental health profession-
als’ involvement with families than
were professionals’ attitudes. The
clinician’s work schedule and profes-
sional discipline were the strongest
predictors, but other organizational
factors posed barriers as well. Dis-
semination of the multiple-family
psychoeducation group model devel-
oped by McFarlane and colleagues
(64,59) has been hindered by a pauci-
ty of programmatic leadership, con-
flicts between the model’s philosophy

and typical agency practices, insuffi-
cient resources, and inadequate at-
tention to human dynamics at the
system level. For example, reason-
able concerns about confidentiality
may be seen as roadblocks to family
involvement rather than as opportu-
nities to create useful innovations
(65). Similar barriers to implementa-
tion of family treatment approaches
have been identified in studies in
Italy (66).

Mental health professionals have
also expressed concern about the cost
and duration of structured family
psychoeducation programs (67), even
though medication and case manage-
ment services for clients usually have
to be continued for much longer pe-
riods than family programs. The lack
of reimbursement for sessions with
families that do not involve the men-
tally ill relative—a characteristic of
many family psychoeducation pro-
grams—is a significant disincentive
to providing such services. Caseloads
are universally high, and staff’s time
is stretched thin. Therefore devoting
substantial human resources to train-
ing, organizing, leading, and sustain-
ing family psychoeducation is seen as
a luxury (16). In such an atmosphere,
horizons tend to be short. The long-
term payoff of fewer crises and hos-
pitalizations and lower total costs of
treatment is overshadowed by imme-
diate organizational crises or short-
term goals (16).

Mental health authorities
At the health-system level, pressures
to focus on outcomes, cost-effective-
ness, and customer satisfaction seem
in principle to favor the widespread
adoption of family information and
support interventions. However, oth-
er tenets of the current health care
environment—such as the emphasis
on short-term cost savings, technical
rather than human-process-oriented
remedies, and individual patholo-
gy—discourage clinicians from pro-
viding such services, which may be
viewed as ancillary. At this level, it
seems that the evidence for family
psychoeducation has not been ac-
cepted. Many of the consumer- and
program-level impediments we have
mentioned are paralleled in the larg-
er administrative systems: lack of

PSYCHIATRIC SERVICES ♦ July 2001 Vol. 52 No. 7 906

The Evidence 7 Review of Research Literature

awareness of evidence, ingrained as-
sumptions about how care should be
structured, and inadequate re-
sources.

Overcoming barriers
to implementation
Research on technology transfer has
identified four fundamental condi-
tions that must be met for change to
occur at the individual or system lev-
el: dissemination of knowledge, eval-
uation of programmatic impact,
availability of resources, and efforts
to address the human dynamics of re-
sisting change (68). Implementation
strategies must include clear, wide-
spread communication of the models
and of their benefits to all stakehold-
ers. This communication must occur
through channels that are accessible
and acceptable to the various stake
holders (16), including families, con-
sumers, providers, administrators,
and policy makers. It must be accom-
panied by advocacy, training, and su-
pervision or consultation initiatives to
raise awareness and support at all or-
ganizational levels (69).

The consumer and family members
At the level of the individual con-
sumer and members of his or her
family, effective treatment models
include strategies for overcoming
barriers to participation, such as
stigma and a sense of hopelessness.
Such strategies include offering to
hold sessions in the home of the
client or family member; helping
family members understand that the
intervention is designed to improve
the lives of everyone in the family,
not just the patient; being flexible
about scheduling family meetings;
and providing education during the
engagement process to destigmatize
mental illness and engender hope
(70,71).

Recent efforts to disseminate fam-
ily psychoeducation in New York
State, Los Angeles, Maine, and Illi-
nois have illustrated clearly the im-
portance of including clients and
their families in the planning, adapta-
tion, and eventual implementation of
family psychoeducation (72). In New
York, dissemination was initiated and
sponsored by the state NAMI chap-
ter (73). Dissemination in Maine and

PSYCHIATRIC SERVICES ♦ July 2001 Vol. 52 No. 7 907

Illinois had dramatically different
outcomes, partly because NAMI’s
Maine chapter provided strong for-
mal support for the effort in that
state, whereas the effort in Illinois
did not involve NAMI’s Illinois chap-
ters (73).

Experience and now some empiri-
cal data illustrate the need to include
consumers and their families in ef-
forts to disseminate family psychoed-
ucation. The tension often encoun-
tered between some consumer advo-
cacy groups and family advocacy or-
ganizations can be bridged by em-
phasizing the complementarity of the
outcomes in family work: as con-
sumers’ symptoms are alleviated and
their functioning improves, their
families become more engaged in
and satisfied with community life,
and both the family burden and med
ical illness decrease (22,74,75).

–

Clinicians and
program administrators
Among professionals working in
community mental health services,
awareness and evidence, although
necessary, are often not sufficient for
adoption of new programs. Although
interventions must adhere to param-
eters of the family psychoeducation
model if good client and family out-
comes are to be achieved, they also
have to be responsive to local organi-
zational and community cultures.
Engagement and implementation
strategies, as well as the interventions
themselves, must be tailored to local
and cultural characteristics, workload
and other stresses faced by clinicians
and agencies, particular diagnoses,
relationships, the duration of illness
and disability, and whether the client
is currently receiving medical treat-
ment (50,76,77).

Perhaps even more critical to the
adoption of family psychoeducation
is the need to match both administra-
tive support and expectations for evi-
dence-based practice with a rationale
and explication of the advantages of
this treatment approach that are
meaningful to clinicians. Advantages
can include avoidance of crises, more
efficient case management, gratitude
from families and consumers, and a
more interesting, invigorating work
environment for clinicians. Recent

studies have shown that on the
whole, knowledge about empirical
advantages of family psychoeduca-
tion, such as reductions in relapse
and rehospitalization rates, carry al-
most no weight in convincing work-
ing clinicians to change their atti-
tudes toward families and adopt new
clinical practices (73).

Consensus building among agency
staff and directors—including a wide
range of concerned parties—in a
process of planning from the bottom
up is critical but must be tailored to
address local operational barriers and
contrary beliefs. In addition, success-
ful implementation of family psy-
choeducation has required ongoing
supervision, operational consulta-
tion, and general support. In a sense,
these characteristics help to build
consensus on an ongoing basis. For
example, the PORT found that it was
possible to change current practice
by providing a high level of technical
assistance and a supportive environ
ment that reflected staff agreement
with the principles and philosophy of
the new program (67). The recent
dissemination of a family psychoedu-
cation program in Los Angeles Coun-
ty succeeded because of the persist-
ent advocacy of the local NAMI
group, the support of top manage-
ment, a nine-month training period,
the high aptitude and strong commit-
ment of the trainees, and the skill of
the trainer (72).

–

Mental health authorities
and government
Although it is tempting to assume
that implementation of family psy-
choeducation could be mandated
centrally by state mental health au-
thorities, experience suggests that a
more complex approach is required.
Dissemination of a family psychoed-
ucation program in New York State
succeeded partly because of a part-
nership between the state, the NAMI
affiliate, and an academic center. Un-
fortunately, the state’s mental health
authority abruptly terminated this
large dissemination program before a
widespread impact could be made.
Maine’s recent success was initiated
by a state trade association of mental
health centers and services, with sup-
port from but little involvement by

Review of Research Literature 8 The Evidence

the state mental health authority,
which recently began exploring a for-
mal partnership to continue and
deepen this largely successful effort.
A simultaneous effort in Illinois, ini-
tiated by the state authority but dis-
tinctly lacking consensus among cen-
ter directors or the state NAMI chap-
ter, has been less successful (73).
One state that has had some success
is New Jersey, which was able to dis-
seminate family psychoeducation by
setting expectations and require-
ments at the state level.

With the exception of the New Jer-
sey effort, experience suggests that
the most promising strategy is one in
which provider organizations take
the initiative with support from con-
sumer and family organizations, the
state mental health authority, and the
key insurance payers. Appropriate
reimbursement for family psychoed-
ucation will follow. Experience also
suggests that several years of consis-
tent effort and ongoing monitoring
are required for success. Fortunately,
this process is not necessarily an ex-
pensive one: Maine implemented its
family psychoeducation program in
more than 90 percent of agencies for
about 25 cents per capita over four
years, including evaluation costs. The
principal costs are in human effort,
especially the effort required to over-
come resistance to change.

Delivery of services to families
must be subject to accountability and
tracking. Although many states en-
courage the delivery of services to
families, few monitor such services or
make funding contingent on the serv-
ices being delivered (78). One sys-
tem-level option is for mental health
centers to create a position for an
adult family intervention coordinator,
who would serve as the contact per-
son for interventions, facilitate com-
munication between staff and fami-
lies, supervise clinicians, and monitor
fidelity (79).

Family-to-Family
Education Program
In the absence of family psychoedu-
cation programs, voluntary peer-led
family education programs have de-
veloped, epitomized by NAMI’s
Family-to-Family Education Pro
gram (FFEP) (14,80–82). FFEP is

–

currently available in 41 states, many
of which have waiting lists. FFEP
and other mutual-assistance family
programs are organized and led by
trained volunteers from families of
persons who have mental illness.

These community programs are of-
fered regardless of the mentally ill
person’s treatment status. They tend
to be brief—for example, 12 weeks
for FFEP—and mix families of per-
sons with various diagnoses, although
they focus on persons with schizo-
phrenia or bipolar disorder. On the
basis of a trauma-and-recovery mod-
el of a family’s experience in coping
with mental illness, FFEP merges
education with specific support
mechanisms to help families through
the various stages of comprehending
and coping with a family member’s
mental illness (14). The program fo-
cuses first on outcomes of family
members and their well-being, al-
though benefits to the patient are
also considered to be important (50).

Uncontrolled research on FFEP
and its predecessor, Journey of Hope,
suggests that the program increases
the participants’ knowledge about
the causes and treatment of mental
illness, their understanding of the
mental health system, and their well-
being (13). In a prospective, natura-
listic study, FFEP participants re-
ported that they had significantly less
displeasure and concern about mem-
bers of their family who had mental
illness and significantly more em-
powerment at the family, community,
and service-system levels after they
had completed the program (83).
Benefits observed at the end of the
program had been sustained six
months after the intervention. Pre-
liminary results from a second ongo-
ing study with a waiting-list control
design have revealed similar findings.

Although FFEP currently lacks
rigorous scientific evidence of effica-
cy in improving clinical or functional
outcomes of persons who have men-
tal illness, it shows considerable
promise for improving the well-being
of family members. In recent re-
search and practice, attempts have
been made to optimize the clinical
opportunities provided by family psy-
choeducation and peer-based pro-
grams such as FFEP by developing

partnerships between the two strate-
gies. For example, family psychoedu-
cation programs have used FFEP
teachers as leaders, and participation
in FFEP has facilitated eventual par-
ticipation in family psychoeducation.

Conclusions
The efficacy and effectiveness of
family psychoeducation as an evi-
dence-based practice have been es-
tablished. To date, the use of family
psychoeducation in routine clinical
practice is alarmingly limited. Re-
search has recently begun to develop
dissemination interventions targeted
at the programmatic and organiza-
tional levels, with some success. On
going research must continue to de-
velop practical and low-cost strate-
gies to introduce and sustain family
psychoeducation in typical practice
settings. Basic research that identi-
fies the barriers to implementing
family psychoeducation in various
clinical settings is also needed—for
example, the impact of clinicians’ at-
titudes, geographic factors, funding,
disconnection of patients from family
members, and stigma—as well as the
extent to which variations in these
factors mediate the outcomes of edu-
cational interventions.

Dissemination could also be facili-
tated by further exploring the inte-
gration of family psychoeducation
with psychosocial interventions—
such as assertive community treat-
ment, supported employment, and
social skills training—and other evi-
dence-based cognitive-behavioral strat-
egies for improving the treatment
outcomes of persons with mental ill-
ness. Promising efforts have com-
bined the energy, enthusiasm, and
expertise of grassroots family organi-
zations such as NAMI with profes-
sional and clinical programs. ♦

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77. Jordan C, Lewellen A, Vandiver V: Psy-
choeducation for minority families: a social-
work perspective. International Journal of
Mental Health 23(4):27–43, 1995

78. Dixon L, Goldman HH, Hirad A: State pol-
icy and funding of services to families of
adults with serious and persistent mental ill-
ness. Psychiatric Services 50:551–552, 1999

79. Mueser KT, Fox L: Family-friendly servic-
es: a modest proposal [letter]. Psychiatric
Services 51:1452, 2000

80. Solomon P, Draine J, Mannion E: The im-
pact of individualized consultation and
group workshop family education interven-
tions in ill relative outcomes. Journal of Ner-
vous and Mental Disease 184:252–255, 1996

81. Solomon P, Draine J, Mannion E, et al: Im-
pact of brief family psychoeducation on
self-efficacy. Schizophrenia Bulletin 22:41–
50, 1996

82. Solomon P: Interventions for families of in-
dividuals with schizophrenia: maximizing
outcomes for their relatives. Disease Man-
agement and Health Outcomes 8:211–221,
2000

83. Dixon L, Stewart B, Burland J, et al: Pilot
study of the effectiveness of the Family-to-
Family Education Program. Psychiatric
Services 52:965–967, 2001

PSYCHIATRIC SERVICES ♦ July 2001 Vol. 52 No. 7

The Evidence 11

Selected Bibliography

The Evidence
Selected Bibliography

Literature reviews

Drake, R. E., Merrens, M. R., &
Lynde, D. W. (2005). Evidence-based
mental health practice: A textbook, New
York: WW Norton.

 Introduces readers to the concepts
and approaches of evidence-
based practices for treating severe
mental illnesses.

 Describes the importance of research
in intervention science and the
evolution of evidence-based practices.

 Contains a chapter for each of five
evidence-based practices and provides
historical background, practice
principles, and an introduction
to implementation. Vignettes
highlight the experiences of staff and
consumers.

 Is an excellent, readable primer for
the Evidence-Based Practices KITs.

Selected Bibliography 12 The Evidence

Resources for family intervention
coordinators and mental health
authorities

Anderson, C. M., Griffin, S., Ross, I. A.,
Pagonis, I., Holder, D. P., & Treiber, R. (1986).
A comparative study of the impact of education
vs. process groups for families of patients with
affective disorders. Family Process, 25, 185-205.

Batalden, P. B., & Stoltz, P. K. (1993). A framework
for the continual improvement of healthcare:
Building and applying professional and
improvement knowledge to test changes in daily
work. The Joint Commission Journal on Quality
Improvement, 19, 424-445.

Falloon, I. R. H., McGill, C. W., & Boyd, J. L.
(1992). Family management in the prevention
of morbidity in schizophrenia: Social outcome
of a two-year longitudinal study. Psychological
Medicine, 17, 59-66.

McFarlane, W. R., Dushay, R. A., Deakins, S. M.,
Stastny, P., Lukens, E. P., Toran, J., et al. (2000).
Employment outcomes in family-aided Assertive
Community Treatment. American Journal of
Orthopsychiatry, 70, 203-214.

Essential reading for practitioners

The following four books are recommended for
those who want to master this approach. The first is
especially helpful for practitioners offering FPE in
the single-family format. The third reference is
recommended for practitioners facilitating
multifamily groups.

Anderson, C., Hogarty, G., & Reiss, D. (1986).
Schizophrenia and the family. New York:
Guilford Press.

Falloon, I., Boyd, J., & McGill, C. (1984). Family
care of schizophrenia. New York: Guilford Press.

McFarlane, W. R. (2002). Multifamily groups in
the treatment of severe psychiatric disorders.
New York: Guilford.

Miklowitz, D. J., & Goldstein, M. (1997). Bipolar
disorder: A family-focused treatment approach.
New York: Guilford Press.

Additional resources for
practitioners

Amenson, C. (1998). Schizophrenia: A family
education curriculum. Pasadena, CA: Pacific
Clinics Institute.

Provides 150 slides with lecture notes for
conducting educational workshops for families
who have a relative with schizophrenia. Includes
information about the illness, medication,
psychosocial treatments, and the role of the
family in promoting recovery.

Amenson, C. (1998). Schizophrenia: Family
education methods. Pasadena, CA: Pacific
Clinics Institute.

A companion handbook to Schizophrenia: A
Family Education Curriculum. Provides guidance
on forming a class, optimizing learning for
families, and dealing with typical problems that
arise in conducting educational workshops.

Kuipers, E., Leff, J. & Lam, D. (2002). Family
work for schizophrenia: A practical guide.
London: Gaskill.

Linehan, M. (1993). Cognitive-behavioral
treatment of borderline personality disorder.
New York: Guilford.

Mueser, K. T., & Glynn, S. (1999). Behavioral
family therapy for psychiatric disorders.
Oakland, CA: New Harbinger Publications.

The Evidence 13 Selected Bibliography

Psychopharmacology

Gorman, J. (1995). The essential guide to
psychiatric drugs. New York: St. Martin’s Press.

Profiles individual medications in easy-to-
understand terms.

Lickey, M., & Gordon, B. (1991). Medicine and
mental illness. New York: W. H. Freeman.

Presents principles of diagnosis, neurophysiology,
and psychopharmacological treatment of mental
illnesses. Describes why psychopharmacology
exists and how it works.

Special topics

Manoleas, P. (Ed.) (1996). The cross-cultural
practice of clinical case management in mental
health. Binghamton, NY: Haworth Press.

Presents a collection of articles about the roles
of gender, ethnicity, and acculturation in seeking
treatment and response. Gives guidelines for
engaging and intervening with specific ethnic and
diagnostic groups in varying treatment contexts.

Russell, L. M., & Grant, A. E. (1995). Planning for
the future: Providing a meaningful life for a child
with a disability after your death. Evanston, IL:
American Publishing Company.

Russell, L. M., & Grant, A. E. (1995). The life
planning workbook: A hands-on guide to
help parents provide for the future security
and happiness of their child with a disability
after their death. Evanston, IL: American
Publishing Company.

Offers guidance to parents on providing for the
future security of adults with mental illnesses.

Silver, D. (1992). A Parent’s guide to wills and
trusts. Los Angeles, CA: Adams-Hall.

Provides financial planning suggestions for
parents of adults with mental illnesses.

Solomon, P., Mannion, E., Marshall, T., &
Farmer, J. (2001). Social workers as consumer
and family consultants. In K. Bentley (Ed.),
Social work practice in mental health:
Contemporary roles, tasks, and techniques
(pp. 230–253). Pacific Grove, CA: Brooks/Cole
Publishing Co.

Provides a model Release of Information form
for sharing information with families on an
ongoing basis.

Wrobleski, A. (1991). Suicide survivors: A
guide for those left behind. Minneapolis, MN:
Afterwords Publishing.

Offers coping strategies to families who have had
a relative commit suicide.

Resources for families

Adamec. C. (1996). How to live with a mentally
ill person: A handbook of day-to-day strategies.
New York: John Wiley and Sons.

This comprehensive, easy-to-read book, written
by a parent, reviews methods for accepting
illness, dealing with life issues, developing coping
strategies, negotiating the mental health system,
and more.

Keefe, R., & Harvey, P. (1994). Understanding
schizophrenia: A guide to the new research
on causes and treatment. New York: The
Free Press.

Describes research and presents the science of
schizophrenia in understandable terms.

Selected Bibliography 14 The Evidence

Marsh, D., & Dickens, R. (1997). Troubled
journey: Coming to terms with the mental
illness of a sibling or parent. New York:
Tarcher/Putnam.

Written for siblings and adult children of people
with mental illnesses. Discusses the impact of
mental illnesses on childhood.

Mueser, K., & Gingerich, S. (1994). Coping with
schizophrenia: A guide for families. Oakland,
CA: New Harbinger Publications.

Offers a comprehensive guide to living with
schizophrenia. Provides practical advice on
topics including medication, preventing relapse,
communication, family rules, drug use, and
planning for the future. Includes forms and
worksheets for solving typical problems.

Torrey, E. F. (1995). Surviving schizophrenia:
A family manual (3rd ed.) New York: Harper
& Row.

First-person accounts

Devesch, A. (1992). Tell me I’m here: One
family’s experience with schizophrenia. New
York: Penguin.

A United Nation’s Media Peace Prize winner and
founder of Schizophrenia Australia describes her
family’s experience.

Dickens, R., & Marsh, D. (1994). Anguished
voices: Siblings and adult children of persons
with psychiatric disabilities. Boston, MA:
Center for Psychiatric Rehabilitation.

Collection of eight stories describing the impact
of mental illnesses on siblings and children. Deals
with the issues across the life span that must be
addressed when someone grows up with mental
illness in the family.

Duke, P., & Hochman, G. (1992). A brilliant
madness: Living with manic depressive illness.
New York: Bantam Books.

Combines personal experience with clinical
information to describe manic depression in
understandable terms and gives guidelines for
coping with it.

Hyland, B. (1986). The girl with the crazy
brother. London: Franklin Watts.

Written for adolescents.

Jamison, K. R. (1995). An Unquiet Mind. New
York: Alfred A. Knopf, Inc.

A compelling and emotional account of author’s
awareness, denial, and acceptance of her bipolar
disorder. It offers readers hope for recovery.

Riley, J. (1984). Crazy quilt. New York:
William Morrow.

Fictional account of a 13-year-old girl whose
mother has schizophrenia. Written for children
and adolescents.

Sheehan, S. (1982). Is there no place on earth for
me? New York: Houghton-Mifflin.

Describes the experience of living with
schizophrenia. Provides information about
legal, funding, and treatment issues. Won the
Pulitzer Prize.

Schiller, L., & Bennett, A. (1994). The quiet room:
A journey out of the torment of madness. New
York: Warner Books.

Wasow, M. (1995). The skipping stone: Ripple
effects of mental illness on the family. Palo Alto,
CA: Science and Behavior Books.

The Evidence 15 Selected Bibliography

Self-help

Burns, D. (1989). The feeling good handbook.
New York: Penguin.

Self-help book presents a rationale for cognitive
therapy for depression with specific ideas and
exercises to help change thought patterns
associated with depression and other problems.

Copeland, M. E. (1992). The depression
workbook. Oakland, CA: New Harbinger
Publications.

Helps consumers take responsibility for wellness
by using charts and techniques to track and
control moods.

Lewinsohn, P., Munoz, R., Youngren, M. A.,
& Zeiss, A. (1979). Control your depression.
Englewood Cliffs, New Jersey: Prentice Hall.

Self-help book assesses what contributes to
depression. Includes techniques and activities
such as relaxation, social skill-enhancement, and
modification of self-defeating thinking patterns.

Papolos, D., & Papolos, J. (1997). Overcoming
depression. (3rd ed.). New York: Harper & Row.

A comprehensive book written for consumers
and families.

Videotapes

Amenson, C. S. Exploring schizophrenia.
Produced by the California Alliance for the
Mentally Ill. (Available from the California
Alliance for the Mentally Ill, 1111 Howe
Avenue, Suite 475, Sacramento, CA 95825.
Phone: (916) 567-0163.)

Uses everyday language to describe
schizophrenia. Provides coping guidelines to
consumers and their families.

American Psychiatric Association (Producer).
(1997). Critical connections: A schizophrenia
awareness video. (Available from American
Psychiatric Association, 1000 Wilson Boulevard,
Suite 1825, Arlington, VA 22209. Phone:
(703) 907-7300.)

This 30-minute video provides a hopeful,
reassuring message about new medications and
psychosocial treatments for schizophrenia.

McFarlane, W. R. (Producer). (1999).
Schizophrenia explained. (Available from W.
R. McFarlane, Maine Medical Center, 22
Bramhall Street, Portland, ME 04102. Phone:
(207) 871-2091. mcfarw@mmc.org.)

Provides a full review in lay language of the
psychobiology of schizophrenia, emphasizing
stress reduction, optimal environments, and
interactions for recovery, and family support. May
be used in FPE 1-day educational workshops.

Vaccaro, J. V. (1996). Exploring bipolar disorder.
Produced by the California Alliance for the
Mentally Ill. (Available from the California
Alliance for the Mentally Ill, 1111 Howe
Avenue, Suite 475, Sacramento, CA 95825.
Phone: (916) 567-0163.)

This 1-hour video describes the bipolar disorder,
recovery, and the role of the family. Consumers
contribute valuable insights.

http://mcfarw@mmc.org

The Evidence 17 References

Anderson, C. M., Griffin, S., Ross, I. A.,
Pagonis, I., Holder, D. P., & Treiber,
R. (1986). A comparative study of the
impact of education vs. process groups
for families of patients with affective
disorders. Family Process, 25, 185–205.

American Psychiatric Association. (1997).
Practice guidelines for the treatment
of patients with schizophrenia. The
American Journal of Psychiatry. 154(4)
Suppl., 1–63.

Becker, D. R., Bond, G. R., McCarthy, D.,
Thompson, D., Xie, H., McHugo, G. J.,
et al. (2001). Converting day treatment
centers to supported employment
programs in Rhode Island. Psychiatric
Services, 52, 351–357.

Becker, D. R., Smith, J., Tanzman, B.,
Drake, R. E., & Tremblay, T. (2001).
Fidelity of supported employment
programs and employment outcomes.
Psychiatric Services, 52, 834–836.

The Evidence

References
The following list includes the references for all citations in the KIT.

References 18 The Evidence

Bogart, T. & Solomon, P. (1999). Collaborative
procedures to share treatment information
among mental health care providers,
consumers, and families. Psychiatric Services,
50, 1321–1325.

Bond, G. R., & Salyers, M. P. (2004). Prediction
of outcome from the Dartmouth ACT Fidelity
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Clarkin, J. F., Carpenter, D., Hull, J.,
Wilner, P., and Glick, I. (1998). Effects of
psychoeducational intervention for married
patients with bipolar disorder and their spouses.
Psychiatric Services, 49, 531–533.

Cuijpers, P. (1999). The effects of family
interventions on relatives’ burden: A meta-
analysis. Journal of Mental Health, 8, 275–285.

Dixon, L. & Lehman, A. F. (1995). Family
interventions for schizophrenia. Schizophrenia
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Dixon, L., McFarlane, W. R., Lefley, H.,
Lucksted, A., Cohen, M., Falloon, I., et al.
(2001). Evidence-based practices for services to
families of people with psychiatric disabilities.
Psychiatric Services, 52, 903–910.

Dyck, D., Hendryx, M. S., Short, R. A.,
Voss, W. D., and McFarlane, W. R. (2002).
Service use among patients with schizophrenia
in psychoeducational multifamily-group
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Emanuels-Zuurveen, L. (1997). Spouse-aided
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Falloon, I. R. H., Held, T., Cloverdale, R.,
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interventions for schizophrenia: A review of
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Psychiatric Rehabilitation Skills, 3, 268–290.

Falloon, I. R. H., & Pederson, J. (1985). Family
management in the prevention of morbidity
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family unit. British Journal of Psychiatry, 147,
156–163.

Ganju, V. (2004, June). Evidence-based practices:
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Gunderson, J., Berkowitz, C., & Ruizsancho,
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Schoenwald, S. K. (2003). Turning knowledge
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schizophrenia: The impact of training on
psychiatric nurses’ attitude and knowledge.
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Leff, J., Berkowitz, R., Shavit, N., Strachan,
A., Glass, I., & Vaughn, C. (1990). A trial of
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schizophrenia: Two-year follow-up. British
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Leff, J., Kuipers, L., Berkowitz, R., & Sturgeon,
D. (1985). A controlled trial of social
intervention in the families of schizophrenic
patients: Two-year follow-up. British Journal of
Psychiatry, 146, 594–600.

http://http://www.tacinc.org

http://www.acmha.org

The Evidence 19 References

Leff, J., Vearnals, S., Brewin, C., Wolff, G.,
Alexander, B., Asen, E., et al. (2000). The
London Depression Intervention Trial:
Randomised controlled trial of antidepressants
v. couple therapy in the treatment and
maintenance of people with depression living
with a partner: Clinical outcome and costs.
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Lehman, A. & Steinwachs, D. (1998). At
issue: translating research into practice: the
schizophrenia patient outcomes research
team (PORT) treatment recommendations.
Schizophrenia Bulletin, 24, 1–10.

Marshall, T. & Solomon, P. (2003). Professionals’
responsibilities in releasing information
to families of adults with mental illness.
Psychiatric Services, 54, 1622–1628

McFarlane, W. R., Dixon, L., Lukens, E., and
Lucksted, A. (2003). Family psychoeducation
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McFarlane, W. R. (2002). Empirical studies
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McFarlane, W. R. (Ed.). (2002). Multifamily
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McFarlane, W. R., Link, B., Dushay,
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McFarlane, W. R., Lukens, E., Link,
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Newmark, M., et al. (1995). Multiple-family
groups and psychoeducation in the treatment of
schizophrenia. Archives of General Psychiatry,
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McFarlane, W. R., Dushay, R. A., Deakins, S. M.,
Stastny, P., Lukens, E. P., Toran, J., et al. (2000).
Employment outcomes in family-aided assertive
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McFarlane, W. R., Dushay, R. A.,
Stastny, P., Deakins, S. M., & Link, B. (1996).
A comparison of two levels of family-aided
assertive community treatment. Psychiatric
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Miklowitz, D. J., Simoneau, T. L., George, E. L.,
Richards, J. A., Kalbag, A., Sachs-Ericsson,
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Miklowitz, D. J., & Goldstein, M. J. (1997).
Bipolar disorder: A family-focused treatment
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Moltz, D. (1993). Bipolar disorder and the family:
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Puche, E., & Adam, A. (1992). The influence
of family expressed emotion on the course of
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The Evidence 23 Acknowledgments

The materials included in the Family Psychoeducation (FPE) KIT were
developed through the National Implementing Evidence-Based Practices
Project. The Project’s Coordinating Center—the New Hampshire-Dartmouth
Psychiatric Research Center—in partnership with many other collaborators,
including clinicians, researchers, consumers, family members, and
administrators, and operating under the direction of the Substance Abuse
and Mental Health Services Administration, Center for Mental Health Services,
developed, evaluated, and revised these materials.

We wish to acknowledge the many people who contributed to all aspects
of this project. In particular, we wish to acknowledge the contributors and
consultants on the following pages.

The Evidence
Acknowledgments

Acknowledgments 24 The Evidence

Michael English
Division of Service and Systems Improvement
Rockville, Maryland

Neal B. Brown
Community Support Programs Branch
Division of Service and Systems Improvement
Rockville, Maryland

Sandra Black
Community Support Programs Branch
Division of Service and Systems Improvement
Rockville, Maryland

Crystal R. Blyler
Community Support Programs Branch
Division of Service and Systems Improvement
Rockville, Maryland

Pamela J. Fischer
Homeless Programs Branch
Division of Service and Systems Improvement
Rockville, Maryland

Lisa Dixon
University of Maryland School of Medicine
Baltimore, Maryland

Donna Downing
Maine Medical Center
Portland, Maine

Sushmita Shoma Ghose
Community Support Programs Branch
Division of Service and Systems Improvement
Rockville, Maryland

Patricia Gratton
Division of Service and Systems Improvement
Rockville, Maryland

Betsy McDonel Herr
Community Support Programs Branch
Division of Service and Systems Improvement
Rockville, Maryland

Larry D. Rickards
Homeless Programs Branch
Division of Service and Systems Improvement
Rockville, Maryland

SAMHSA Center for Mental Health Services, Oversight Committee

Co-Leaders

William R. McFarlane
Maine Medical Center
Portland, Maine

The Evidence 25 Acknowledgments

Contributors

Curtis Adams
University of Maryland School of Medicine
Baltimore, Maryland

Christopher S. Amenson
Pacific Clinics Institute
Pasadena, California

Carol Anderson
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania

Charity Appell
Ascutney, Vermont

Cynthia Bisbee
Montgomery, Alabama

Gary Bond
Indiana University–Purdue University
Indianapolis, Indiana

Judy Burk
Bangor, Maine

Jose Canive
University of New Mexico Health Sciences Center
Albuquerque, New Mexico

Diane Chambers
Vermont Department of Health
Agency of Human Services
Burlington, Vermont

Michael J. Cohen
National Alliance on Mental Illness (NAMI)
Concord, New Hampshire

Cathy Donahue
Calais, Vermont

Dennis Dyck
Washington State University
Spokane, Washington

Kana Enomoto
Substance Abuse and Mental Health Services
Administration
Rockville, Maryland

Ian Falloon
University of Auckland
Auckland, New Zealand

Laurie Flynn
Alexandria, Virginia

Risa Fox
Community Support Programs Branch
Division of Service and Systems Improvement
Rockville, Maryland

Shirley M. Glynn
U.S. Department of Veteran Affairs
Greater Los Angeles Healthcare System
Los Angeles, California

Linda H. Jacobson
Maine Medical Center
Portland, Maine

Dale Johnson
University of Houston
Houston, Texas

Gabor Keitner
Brown University
Providence, Rhode Island

Alex Kopelowicz
University of California
Los Angeles School of Medicine
Los Angeles, California

Mary Beth Lapin
Portland, Maine

Julian Leff
Kings College, Institute of Psychiatry
London, United Kingdom

Acknowledgments 26 The Evidence

Charles A. Rapp
The University of Kansas
Lawrence, Kansas

Dennis Ross
Marshfield, Vermont

Nina R. Schooler
Georgetown University
School of Medicine
Washington, D.C.

Jacqueline Shannon
San Angelo, Texas

Mary Kay Smith
University of Toledo
College of Medicine
Toledo, Ohio

Phyllis Solomon
University of Pennsylvania,
School of Social Policy and Practice Philadelphia,
Pennsylvania

Diane Sondheimer
SAMHSA Center for Mental Health Services
Rockville, Maryland

Bette Stewart
University of Maryland School of Medicine
Baltimore, Maryland

Karin Swain
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

William Torrey
Dartmouth Medical School
Hanover, New Hampshire

Suzanne Vogel-Scibilia
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania

Harriet P. Lefley
University of Miami
School of Medicine
Miami, Florida

Steven R. Lopez
University of California
Los Angeles Department of Psychology
Los Angeles, California

Ken Lutterman
National Institutes of Health
Bethesda, Maryland

David W. Lynde
Dartmouth Psychiatric Research Center
Concord, New Hampshire

Doug Marty
The University of Kansas
Lawrence, Kansas

Gregory J. McHugo
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

Matthew Merrens
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

David J. Miklowitz
University of Colorado
Department of Psychology and Psychiatry
Boulder, Colorado

Kim T. Mueser
Dartmouth Psychiatric Research Center
Concord, New Hampshire

Ernest Quimby
Howard University
Washington, D.C.

The Evidence 27 Acknowledgments

Consultants to the National Implementing Evidence-Based Practices Project

Dan Adams
St. Johnsbury, Vermont

Diane C. Alden
New York State Office of Mental Health
New York, New York

Lindy Fox Amadio
Dartmouth Psychiatric Research Center
Concord, New Hampshire

Diane Asher
The University of Kansas
Lawrence, Kansas

Stephen R. Baker
University of Maryland School of Medicine
Baltimore, Maryland

Stephen T. Baron
Department of Mental Health
Washington, D.C.

Deborah R. Becker
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

Nancy L. Bolton
Cambridge, Massachusetts

Patrick E. Boyle
Case Western Reserve University
Cleveland, Ohio

Mike Brady
Adult and Child Mental Health Center
Indianapolis, Indiana

Ken Braiterman
National Alliance on Mental Illness (NAMI)
Concord, New Hampshire

Janice Braithwaite
Snow Hill, Maryland

Michael Brody
Southwest Connecticut Mental Health Center
Bridgeport, Connecticut

Mary Brunette
Dartmouth Psychiatric Research Center
Concord, New Hampshire

Sharon Bryson
Ashland, Oregon

Barbara J. Burns
Duke University School of Medicine
Durham, North Carolina

Jennifer Callaghan
The University of Kansas
School of Social Welfare
Lawrence, Kansas

Kikuko Campbell
Indiana University–Purdue University
Indianapolis, Indiana

Linda Carlson
University of Kansas
Lawrence, Kansas

Diana Chambers
Department of Health Services
Burlington, Vermont

Alice Claggett
University of Toledo College of Medicine
Toledo, Ohio

Marilyn Cloud
Department of Health and Human Services
Concord, New Hampshire

Melinda Coffman
The University of Kansas
Lawrence, Kansas

Acknowledgments 28 The Evidence

Jon Collins
Office of Mental Health and Addiction Services
Salem, Oregon

Laurie Coots
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

Judy Cox
New York State Office of Mental Health
New York, New York

Harry Cunningham
Dartmouth Psychiatric Research Center
Concord, New Hampshire

Gene Deegan
University of Kansas
Lawrence, Kansas

Natalie DeLuca
Indiana University–Purdue University
Indianapolis, Indiana

Robert E. Drake
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

Molly Finnerty
New York State Office of Mental Health
New York, New York

Laura Flint
Dartmouth Evidence-Based Practices Center
Burlington, Vermont

Vijay Ganju
National Association of State Mental Health
Program Directors Research Institute
Alexandria, Virginia

Susan Gingerich
Narberth, Pennsylvania

Phillip Glasgow
Wichita, Kansas

Howard H. Goldman
University of Maryland School of Medicine
Baltimore, Maryland

Paul G. Gorman
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

Gretchen Grappone
Concord, New Hampshire

Eileen B. Hansen
University of Maryland School of Medicine
University of Maryland, Baltimore

Kathy Hardy
Strafford, Vermont

Joyce Hedstrom
Courtland, Kansas

Lon Herman
Department of Mental Health
Columbus, Ohio

Lia Hicks
Adult and Child Mental Health Center
Indianapolis, Indiana

Debra Hrouda
Case Western Reserve University
Cleveland, Ohio

Bruce Jensen
Indiana University–Purdue University
Indianapolis, Indiana

Clark Johnson
Salem, New Hampshire

Amanda M. Jones
Indiana University–Purdue University
Indianapolis, Indiana

Joyce Jorgensen
Department of Health and Human Services
Concord, New Hampshire

Hea-Won Kim
Indiana University–Purdue University
Indianapolis, Indiana

The Evidence 29 Acknowledgments

David A. Kime
Transcendent Visions and Crazed Nation Zines
Fairless Hills, Pennsylvania

Dale Klatzker
The Providence Center
Providence, Rhode Island

Kristine Knoll
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

Bill Krenek
Department of Mental Health
Columbus, Ohio

Rick Kruszynski
Case Western Reserve University
Cleveland, Ohio

H. Stephen Leff
The Evaluation Center at the Human Services
Research Institute
Cambridge, Massachusetts

Treva E. Lichti
National Alliance on Mental Illness (NAMI)
Wichita, Kansas

Wilma J. Lutz
Ohio Department of Mental Health
Columbus, Ohio

Anthony D. Mancini
New York State Office of Mental Health
New York, New York

Paul Margolies
Hudson River Psychiatric Center
Poughkeepsie, New York

Tina Marshall
University of Maryland School of Medicine
Baltimore, Maryland

Ann McBride
Oklahoma City, Oklahoma

William R. McFarlane
Maine Medical Center
Portland, Maine

Mike McKasson
Adult and Child Mental Health Center
Indianapolis, Indiana

Alan C. McNabb
Ascutney, Vermont

Meka McNeal
University of Maryland School of Medicine
Baltimore, Maryland

Ken Minkoff
ZiaLogic
Albuquerque, New Mexico

Michael W. Moore
Office of Mental Health and Addiction Services
Salem, Oregon

Roger Morin
The Center for Health Care Services
San Antonio, Texas

Lorna Moser
Indiana University–Purdue University
Indianapolis, Indiana

Kim T. Mueser
Dartmouth Psychiatric Research Center
Concord, New Hampshire

Britt J. Myrhol
New York State Office of Mental Health
New York, New York

Bill Naughton
Southeastern Mental Health Authority
Norwich, Connecticut

Nick Nichols
Department of Health
Burlington, Vermont

Selected Bibliography 30 The Evidence

Bernard F. Norman
Northeast Kingdom Human Services
Newport, Vermont

Linda O’Malia
Oregon Health and Science University
Portland, Oregon

Ruth O. Ralph
University of Southern Maine
Portland, Maine

Angela L. Rollins
Indian University–Purdue University
Indianapolis, Indiana

Tony Salerno
New York State Office of Mental Health
New York, New York

Diana C. Seybolt
University of Maryland School of Medicine
Baltimore, Maryland

Patricia W. Singer
Santa Fe, New Mexico

Mary Kay Smith
University of Toledo
Toledo, Ohio

Diane Sterenbuch
Bethesda, Maryland

Bette Stewart
University of Maryland School of Medicine
Baltimore, Maryland

Steve Stone
Mental Health and Recovery Board
Ashland, Ohio

Maureen Sullivan
Department of Health and Human Services
Concord, New Hampshire

Beth Tanzman
Vermont Department of Health
Burlington, Vermont

Greg Teague
University of Southern Florida
Tampa, Florida

Boyd J. Tracy
Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

Laura Van Tosh
Olympia, Washington

Joseph A. Vero
National Alliance on Mental Illness (NAMI)
Aurora, Ohio

Barbara L. Wieder
Case Western Reserve University
Cleveland, Ohio

Mary Woods
Westbridge Community Services
Manchester, New Hampshire

The Evidence 31 Acknowledgments

The following organizations for their generous contributions:

 The John D. & Catherine T. MacArthur Foundation

 West Family Foundation

Carolyn Boccella Bagin
Center for Clear Communication, Inc.
Rockville, Maryland

Sushmita Shoma Ghose
Westat
Rockville, Maryland

Julien Hofberg
Westat
Rockville, Maryland

Glynis Jones
Westat
Rockville, Maryland

Special thanks to

Production, editorial, and graphics support

Chandria Jones
Westat
Rockville, Maryland

Tina Marshall
Gaithersburg, Maryland

Mary Anne Myers
Westat
Rockville, Maryland

Robin Ritter
Westat
Rockville, Maryland

26174.0609.7765020404

HHS Publication No. SMA-09-4422
Printed 2009

• The Evidence-Cover
• Title Page

Acknowledgments
The Evidence

• What’s in The Evidence

Review of Research Literature

• Evidence-Based Practices forServices to Families of People With Psychiatric Disabilities

Selected Bibliography
Literature reviews
Resources for family intervention coordinators and mental health authorities
Essential reading for practitioners
Additional resources for practitioners
Psychopharmacology
Special topics
Resources for families
First-person accounts
Self-help
Videotapes
References
Acknowledgments
SAMHSA Center for Mental Health Services, Oversight Committee
Co-Leaders
Contributors
Consultants to the National Implementing Evidence-Based Practices Project
Special thanks to
Production, editorial, and graphics support

Evaluating

Your Program

Family

Psychoeducation

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

http://www.samhsa.gov

Family
Psychoeducation
Evaluating
Your Program

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

Acknowledgments

This document was prepared for the Substance Abuse and Mental Health Services
Administration (SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center
under contract number 28

0

-00-8049 and Westat under contract number 270-03-6005,
with SAMHSA, U.S. Department of Health and Human Services (HHS). Neal Brown, M.P.A.,
and Crystal Blyler, Ph.D., served as SAMHSA Government Project Officers.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors
and do not necessarily reflect the views, opinions, or policies of the Center for Mental Health
Services (CMHS), SAMHSA, or HHS.

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced
or copied without permission from SAMHSA. Citation of the source is appreciated. However,
this publication may not be reproduced or distributed for a fee without the specific, written
authorization from the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be downloaded or ordered at http://www.samhsa.gov/shin. Or, please
call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English
and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration. Family Psychoeducation: Evaluating
Your Program. HHS Pub. No. SMA-09-4422, Rockville, MD: Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration, U.S. Department of Health and
Human Services, 2009.

Originating Office

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
Rockville, MD 20857

HHS Publication No. SMA-09-4422
Printed 2009

http://www.samhsa.gov/shin

Family
Psychoeducation

Evaluating Your Program

Evaluating Your Program

shows quality assurance team members
how to evaluate the effectiveness of your Family Psychoeducation
program. It includes the following:

n A readiness assessment;

n The Family Psychoeducation Fidelity Scale;

n The General Organizational Index; and

n Outcome measures that are specific to your program.

You will also find instructions for conducting assessments and tips
on how to use the data to improve your program.

For references see the booklet, The Evidence.

This KIT is part of a series of Evidence-Based Practices KITs created
by the Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration, U.S. Department of Health
and Human Services.

This booklet is part of the Family Psychoeducation KIT that includes
a DVD, CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Staff

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP

What’s in Evaluating Your Program

Why Evaluate Your Family Psychoeducation Program?

. . . . . 1

Conduct a Readiness Assessment

. . . . . . . . . . . . . . . . . . . . 3

Conduct Process Assessments

. . . . . . . . . . . . . . . . . . . . . . . 5

Monitor Outcomes

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Use Data to Improve Your Program

. . . . . . . . . . . . . . . . . . 17

Appendix A:

Cover

Sheet—Family Psychoeducation Fidelity
Scale and General Organizational Index . . . . . 23

Appendix B: Checklist—Observation of Multifamily
Group Sessions . . . . . . . . . . . . . . . . . . . . . . . 27

Appendix C: Family Psychoeducation Fidelity
Scale and Scoresheet . . . . . . . . . . . . . . . . . . 31

Appendix D: Family Psychoeducation Fidelity
Scale Protocol . . . . . . . . . . . . . . . . . . . . . . . 37

Appendix E: General Organizational
Index and Scoresheet . . . . . . . . . . . . . . . . . . 49

Appendix F: General Organizational Index Protocol . . . . . . 55

Appendix G: Outcomes Report Form . . . . . . . . . . . . . . . . . 69

Appendix H: Instructions for the Outcomes Report Form . . 73

Appendix I: Assessor Training and Work
Performance Checklist . . . . . . . . . . . . . . . . . 79

Family
Psychoeducation

Evaluating Your Program 1 Why Evaluate Your Family Psychoeducation Program

Evaluating Your Program

Why Evaluate Your Family Psychoeducation Program?

Key stakeholders who are implementing
Family Psychoeducation (FPE) programs
may find themselves asking two questions:

n Has the program been implemented
as planned?

n Has the program resulted in the
expected outcomes?

Asking these two questions and using the
answers to help improve your program are
critical for ensuring the success of your
FPE program.

To answer the first question, collect
process measures (by using the FPE

Fidelity Scale and General Organizational
Index). Process measures capture how
services are provided. To answer the second
question, collect outcome measures.
Outcome measures capture the results
or achievements of your program.

As you prepare to implement your
program, we strongly recommend that you
develop a quality assurance system using
both process and outcome measures to
monitor and improve the quality of the
program from the startup phase and
continuing through the life of the program.

Why Evaluate Your Family Psychoeducation Program 2 Evaluating Your Program

Why you should collect
process measures

Process measures give you an objective, structured
way to determine if you are delivering services in
the way that research has shown will result in
desired outcomes. Process measures allow agencies
to understand whether they are providing services
that are faithful to the evidence-based model.
Programs that adhere closely to the FPE model
are more effective than those that do not follow
the model. Adhering to the model is called fidelity.

Collecting process measures is an excellent method
to diagnose program weaknesses while helping
to clarify program strengths. Once FPE programs
reach high fidelity, ongoing monitoring allows
you to test local innovations while ensuring that
programs do not drift from the core principles
of the evidence-based practice.

Process measures also give mental health
authorities a comparative framework to evaluate
the quality of FPE programs across the state.
They allow mental health authorities to identify
statewide trends and exceptions to those trends.

Why you should collect
outcome measures

While process measures capture how services are
provided, outcome measures capture the program’s
results. Every service intervention has both
immediate and long-term consumer goals. In
addition, consumers have goals for themselves,
which they hope to attain with the help of mental
health services. These goals translate into outcomes
and the outcomes translate into specific measures.

Consumer outcomes are the bottom line for
mental health agencies, like profit is in business.
No successful businessperson would assume that
the business was profitable just because employees
work hard.

Why develop a quality
assurance system

In your mental health system, you should develop
a quality assurance system that collects not only
process measures such as those on the FPE Fidelity
Scale and General Organizational Index, but also
outcome measures such as those specified above
to show the effect of FPE. Developing a quality
assurance system will help you do the following:

n Diagnose your program’s strengths and
weaknesses;

n Formulate action plans for improving your
program;

n Help consumers achieve their goals for recovery;
and

n Deliver mental health services both efficiently
and effectively.

Research Has Shown That You Can
Expect These Outcomes from Your
FPE Program

n Reduced relapse and hospitalization

n Improved family well-being

n Increased participation in vocational
rehabilitation

n Higher rates of employment, when
combined with Supported Employment

n Decreased costs of care

Evaluating Your Program 3

Conduct a

Readiness Assessment

Evaluating Your Program
Conduct a Readiness Assessment

Let’s assume that administrators and
family intervention coordinators have read
Building Your Program. Your new FPE
practitioners have completed Training
Frontline Staff. How do you know if you
are ready to begin providing FPE services
to consumers?

The Readiness Assessment on the next
page will help quality assurance team
members, advisory group leaders, and
family intervention coordinators track

the processes and administrative tasks
required to develop an FPE program.

Answering these questions will help
you generate an ongoing to-do list (or
implementation plan) to guide your steps
in implementing your FPE program. Your
answers will also help you understand the
components of the FPE model that are
already in place in your agency and the
work that still remains.

Conduct a Readiness Assessment 4 Evaluating Your Program

Readiness Assessment

Check any areas that you feel you do NOT completely understand.

q Which practitioners will be designated as staff for your
FPE program?

q Who will supervise and direct the FPE program
(who will be the family intervention coordinator)?

q What are the roles of the family intervention
coordinator and practitioners?

q What is the size of the FPE practitioners’ caseloads?

q What is the supervisory structure (how often does
the family intervention coordinator meet with FPE
practitioners and the agency director)?

q How will you identify and refer consumers to your
FPE program?

q How will you inform consumers, families, and others
of your FPE program?

q What are your assessment procedures for consumers
in your FPE program?

q How will you document the provision of FPE services?

q How often will FPE sessions be offered?

q How long will consumers and families receive FPE?

q What is your planning process for arranging the
FPE one-day educational workshop?

q How will FPE consumers and families have access
to multimedia educational materials?

q When will you offer FPE multifamily groups?

q How will you measure your program’s fidelity to
the evidence-based model and use this information
to improve your program?

q How will you collect and use consumer outcomes
data?

q How does your FPE staff relate to advisory groups?

Note areas where you still are unclear or have questions. Arrange to speak to an expert consultant or experienced family

intervention coordinator.

Evaluating Your Program 5

Conduct Process Assessments

Evaluating Your Program
Conduct Process Assessments

In addition to the Readiness Assessment,
you should conduct your first process
assessment before you begin providing
any FPE services. By doing so you will
determine whether your agency has core
components of the evidence-based practice
in place. During the first 2 years of
implementing your FPE program, plan
to assess your program every 6 months.

After your program has matured and
achieved high fidelity, you may choose to
conduct assessments once a year. Agencies
that have successfully implemented FPE
programs indicate that you must continue

to evaluate the process to ensure that you
do not revert to previous practice patterns.

Once your program has achieved high
fidelity to the evidence-based model,
FPE practitioners may tailor the program
to meet individual needs of the community.
If you continue to use process assessments
along with outcomes monitoring, you
will be able to understand the extent
to which your changes result in your
program’s departure from model fidelity
and whether the changes positively or
negatively affect consumers.

Conduct Process Assessments 6 Evaluating Your Program

How to use process measures

Two tools have been developed to monitor how
FPE is provided:

n The FPE Fidelity Scale; and

n General Organizational Index.

You may administer both tools at the same time.

The FPE Fidelity Scale has 14 program-specific
items. Each item is rated on a 5-point scale, ranging
from 1 (not implemented) to 5 (fully implemented).
The items assess whether the program is provided
as the evidence-based model prescribes.

The General Organizational Index is a second set
of process measures that has been developed.
In contrast to fidelity scales, which are practice-
specific, this assessment can be used when
implementing any evidence-based practice.
It measures agency-wide operating procedures
that have been found to affect agencies’ overall
capacity to implement and sustain any evidence-
based practice.

For the FPE Fidelity Scale and General
Organizational Index, see Appendices C and E.
You can also print these forms from the CD-ROM
in the KIT.

About the Process Measures that Are Included in the KIT

Quality assurance measures have been developed
and are included in all Evidence-Based Practices KITs.

The FPE Fidelity Scale was developed by a
group of researchers at Indiana University-Purdue
University, Indianapolis, and the developers of
the KIT. The standards used for establishing the
anchors for the “fully implemented” ratings were
determined through a variety of expert sources
as well as through empirical research. The scale
has undergone numerous drafts and review by

many groups. Revisions were also made based
on feedback from a variety of sources during
the 3-year pilot testing of the KIT materials.

The General Organizational Index, developed
by Robert Drake and Charlie Rapp, is a newly
developed scale. This scale has undergone multiple
revisions based on feedback gathered during the
3-year pilot testing of the KIT materials.

Evaluating Your Program 7 Conduct Process Assessments

Who can conduct process assessments?

We recommend enlisting two assessors to conduct
your process assessment. Data collected by two
assessors simultaneously increase the likelihood
that information will be reliable and valid.

Agencies that have successfully implemented FPE
programs have taken different approaches to
identify assessors. Some agencies train FPE
Advisory Committee members as assessors and
rotate the responsibility of completing assessments.
Others have pre-existing quality assurance teams
and simply designate members of the team to
complete assessments of their FPE program. In
other cases, the mental health authorities have
designated staff to conduct assessments.

Assessments can be conducted either internally by
your agency or program or externally by a review
group. External review groups have a distinct
advantage because they use assessors who are
familiar with FPE but, at the same time, are
independent. The goal is to select objective and
competent assessors.

Although we recommend using external assessors,
agencies can also use internal staff to rate their
own programs. The validity of these ratings (or any
ratings, for that matter) depends on the following:

n The knowledge of the person making the ratings;

n Access to accurate information pertaining to the
ratings; and

n The objectivity of the ratings.

If you do conduct your assessments using internal
staff, beware of potential biases of raters who are
invested in seeing the program look good or who
do not fully understand FPE. It is important for
ratings to be made objectively and that they be
based on hard evidence.

Circumstances will dictate decisions in this area,
but we encourage agencies to choose a review
process that fosters objectivity in ratings, for
example, by involving a practitioner who is not
centrally involved in providing FPE. Only people
who have experience and training in interviewing
and data collection procedures (including chart
reviews) should conduct assessments. Additionally,
assessors need to understand the nature and
critical ingredients of the evidence-based model.

If your agency chooses to use a consultant or
trainer to help implement your FPE program,
involving that person in the assessment process
will enhance the technical assistance you receive.
Whichever approach you choose, we encourage
you to make these decisions early in the planning
process. For a checklist to help evaluate assessors’
training and work performance, see Appendix I.

How to conduct process assessments

A number of activities take place before, during,
and after a process assessment. In general,
assessments include the following:

n Interviewing administrators, the family
intervention coordinator, FPE practitioners,
consumers, and families;

n Interviewing other agency staff (psychiatrists,
therapists, or case managers);

n Observing one or more group or individual
sessions;

n Observing a planning and supervisory meeting;
and

n Conducting a chart review.

Collecting information from multiples sources
helps assessors more accurately capture how
services are provided. A day-long site visit
is the best way to learn this information.

Conduct Process Assessments 8 Evaluating Your Program

To save time, you may interview FPE practitioners
in a group. If the FPE program has three or fewer
FPE practitioners, you should interview all of
them. If the program has more than three FPE
practitioners, you should try to interview at least
three of them.

For the items that require interviews with
consumers and family members, we suggest that
you interview at least three (from unique families).
Try to interview families who are at different stages
of the educational process. Contact the family
intervention coordinator to help identify and set up
these interviews. The following suggestions outline
steps in the assessment process.

Before the process assessment

n n n Prepare your assessment questions

A detailed protocol has been developed to
help you understand each item on the FPE
Fidelity Scale and General Organizational
Index, the rationale for why it was included,
guidelines for the types of information to
collect, and instructions for completing
your ratings. Use the protocols to help
prepare the questions that you will ask
during your assessment visit. For the FPE
Fidelity Scale and General Organizational
Index protocols, see Appendices D and F.

While we expect that quality assurance
teams will select which outcome measures
meet your agency’s needs, you should use
the FPE Fidelity Scale and General
Organizational Index in full. Collecting data
for all the items on these scales will allow
your agency to gain a comprehensive
understanding of how closely your program
resembles the evidence-based model.

n n n Create a timeline for the assessment

List all the necessary activities leading
up to and during the visit and create a
timeline for completing each task. Carefully
coordinating efforts, particularly if you have
multiple assessors, will help you complete
your assessment in a timely fashion.

n n n Establish a contact person

Have one key person in the FPE program
arrange your visit and communicate
beforehand the purpose and scope of your
assessment to people who will participate
in interviews. Typically, this contact person
will be the family intervention coordinator.

Exercise common courtesy and show
respect for competing time demands by
scheduling well in advance and making
reminder calls to confirm interview dates
and times.

n n n Establish a shared understanding
with the staff of the FPE program

The most successful assessments are those
in which assessors and the FPE staff share
the goal of understanding how the program
is progressing according to evidence-based
principles. If administrators or FPE
practitioners fear that they will lose funding
or look bad if they don’t score well, then the
accuracy of the data may be compromised.
The best assessment is one in which all
parties are interested in learning the truth.

n n n Indicate what you will need from
respondents during your visit

In addition to the purpose of the
assessment, briefly describe what
information you need, with whom you
must speak, and how long each interview
will take to complete.

Evaluating Your Program 9 Conduct Process Assessments

The visit will be most efficient if the family
intervention coordinator gathers
beforehand as much of the following
information as possible:

n Roster of FPE staff (roles and full-time
equivalents [FTEs]);

n Number of consumers the agency serves;

n Number of consumers actively receiving
FPE;

n Number of consumers and families
who have attended:

Three or more joining sessions;

Educational workshop; and

Each multifamily group;

n Number of consumers served through
the FPE program in the past 6 months;

n Number of consumers who have
dropped out of the FPE program in the
past 6 months;

n A copy of the agency’s brochure or
mission statement for the FPE program;

n A copy of the policies, procedures, and
forms used to identify consumers for
FPE;

n A copy of the policies, procedures, and
forms used with consumers in the FPE
program for assessment and treatment
planning;

n A copy of the curriculum used in the
educational workshop;

n A copy of the curriculum used to train
agency staff on the evidence-based
model; and

n A copy of the agency’s quality assurance
procedures, specifically a list of process
and outcome measures used to evaluate
the FPE program.

Reassure the family intervention
coordinator that you will be able to
conduct the assessment, even if all of the
requested information is unavailable.
Indicate that some information is more
critical (for example, number of FPE
practitioners and number of consumers in
the FPE program) than other information.

Tell the contact person that you must
observe a planning meeting, a group
supervision meeting, and a multifamily
group session during your visit. These are
important factors in determining when you
should schedule your visit.

Observing an FPE multifamily group
is integral to the assessment process.
If observing a multifamily group session
is impossible during your visit, arrange to
have the sessions videotaped before your
site visit.

n n n Alert your contact person that you will
need to sample 10 charts

From an efficiency standpoint, it is
preferable that the charts be drawn
beforehand, using a random selection
procedure. There may be a concern that
the evaluation may be invalidated if FPE
practitioners handpick charts or update
them before the visit. If you both
understand that the goal is to learn how
the program is implementing services,
this is less likely to occur.

Additionally, you can further ensure
random selection by asking for 20 charts
and randomly selecting 10 to review.
Other options include asking for a de-
identified list (i.e., with names removed)
of consumers who receive FPE and using
the list to choose 10 charts to review.

Conduct Process Assessments 10 Evaluating Your Program

If the program only has one FPE
practitioner with fewer than 10 consumers
on its caseload, then review the charts for
all consumers in the program.

n n n Clarify reporting procedures

With the appropriate people (agency
administrators, the mental health authority,
or the family intervention coordinator),
clarify who should receive a report of the
assessment results. Recipients may include
the following:

n Agency administrators;

n Members of the agency’s quality
assurance team;

n Members of the FPE Advisory
Committee;

n The family intervention coordinator;

n FPE practitioners; and

n Consumers and families.

Assessors should also clarify how the
agency would like the report to be
distributed. For example, assessors may
mail or fax the report and follow up to
discuss the results in a meeting or by
conference call.

n n n Organize your assessment materials

Four forms have been created to help you
conduct your assessment:

n The first form is a cover sheet for
the FPE Fidelity Scale and General
Organizational Index, which is
intended to help you organize your
process assessment. It captures general
descriptive information about the
agency, data collection, and community
characteristics.

n The second form is a designed to help
you collect data on two FPE fidelity
items (Items 11 and 12). Complete this
form to record information collected

during your observation of FPE
multifamily group sessions.

n The third and fourth forms are
scoresheets for the two scales. They
help you compare assessment ratings
from one time period to the next. They
may also be useful if you are interested
in graphing results to examine your
progress over time.

For the FPE Fidelity Scale and General
Organizational Index instruments, cover
sheet, checklist, and scoresheets, see
Appendices A, B, C and E. You can also
print these forms from the CD-ROM in
the KIT.

During your assessment visit

n n n Tailor your terminology

To avoid confusion during your interviews,
tailor your terminology. For example, an
FPE program may use client instead of
consumer or it may use clinician instead of
practitioner. Every agency has specific job
titles for particular staff roles. By adopting
the local terminology, you will
improve communication.

n n n Conduct your chart review

It is important that you conduct your chart
review from a representative sample of
charts. When you begin your chart review,
note whether your sample reflects families
of consumers in different stages of the
educational process. You should also note
whether your sample includes consumer
charts from each FPE practitioners’
caseload. Selecting charts of consumers
who have received at least five FPE
sessions is preferred. If your random
sample is not representative in this
manner, consider supplementing your
sample with selected charts that will
increase its representativeness.

Evaluating Your Program 11 Conduct Process Assessments

Within each chart, examine the screening,
referral, assessment, and treatment
planning forms. Review recent Progress
Notes to understand the amount and type
of contact that FPE practitioners have with
the consumers on their caseloads and with
their treatment team members. If Progress
Notes are not integrated into consumer
charts, then ask if FPE practitioners have
any additional files that you may review.

In some cases, a lag may exist between
when a service is given and when it is
documented in the consumer’s chart.
To get the most accurate representation
of services rendered when you sample
chart data, try to gather data from the
most recent time period in which
documentation is completed in full.

To ascertain the most up-to-date time
period, ask the family intervention
coordinator, FPE practitioners, or
administrative staff. Avoid getting an
inaccurate sampling of data where office-
based services might be charted more
quickly than services given in the field.

n n n If discrepancies between sources occur,
query the family intervention coordinator

The general strategy in conducting fidelity
assessments is to obtain data from as many
sources as possible. When all these data
sources converge, you can be more
confident in the validity of the ratings.
However, sometimes sources disagree.

The most common discrepancy is likely
to occur when the family intervention
coordinator’s interview gives a more
idealistic picture of the team’s functioning
than the chart and observational data do.
For example, on the FPE Fidelity Scale,
Assertive engagement and outreach (Item
14) assesses whether FPE practitioners
assertively engage all potential consumers
and family members in the FPE program.

The chart review may show that consumers
who drop out of the program are not
contacted, while the family intervention
coordinator may indicate that FPE
practitioners expend considerable time
reaching out to consumers who have
disengaged from the program.

To understand and resolve this
discrepancy, the assessor should ask
the family intervention coordinator
the following:

Our chart review shows 10 percent of
consumers who disengage are contacted,
but your estimate is much higher. Would
you help us understand the difference?

Often the family intervention coordinator
can provide information that will resolve
the discrepancy.

n n n Before you leave, check for missing data

Fidelity scales should be completed in full,
with no missing data on any items. Check
in with the family intervention coordinator
at the end of the visit to collect any
additional information you may need.

Conduct Process Assessments 12 Evaluating Your Program

After your assessment visit

n n n Followup

It is important to collect any missing data
before completing your rating. If necessary,
follow up on any missing data (for example,
by calling or sending an e-mail). This
would include discussing with the family
intervention coordinator any discrepancies
between data sources that you notice after
you’ve completed the visit.

n n n Score the scales

The purpose of the scale is to assess fidelity
to the evidence-based practice at the
program level, rather than at the level of
a specific practitioner. Ratings are based
on current behavior and activities, not
on planned or intended behavior. For
example, to get full credit (to code the
item as “5”) for Family intervention
coordinator (Item 1), the program must
have a designated staff member fulfilling
the tasks of this position. If the agency
plans to hire personnel to fill the position,
it would not receive credit. If you assess
an agency for the first time to determine
which components of the evidence-based
model the agency already has in place,
some items may not apply.

Many agencies that are developing a new
FPE program will receive low fidelity
ratings on items for which the agency
has not yet formulated its policies and
procedures. For example, several items
are based on evaluating services that are

provided by designated trained FPE
practitioners. Agencies that have not yet
hired or assigned and trained FPE
practitioners, identified consumers and
families, offered an FPE 1-day educational
workshop, or started an FPE multifamily
group cannot be rated for these items.
If an item cannot be rated, code the item
as “1.”

To receive full credit, many items require
that the family intervention coordinator
and practitioners both understand and
apply the evidence-based practice principle.
If FPE practitioners generally do not
understand the concepts, then code that
item as “1.” If they understand parts of
the concept and apply the understanding
consistently, code the item as “3.” To
receive full credit, there must be evidence
that the concepts are applied consistently.

For a complete explanation of how to rate
each item, see the FPE Fidelity Scale
Protocol and General Organizational Index
Protocols in Appendices D and F.

n n n Complete scales independently

If you have two assessors, both should
independently review the data collected and
rate the scales. They should then compare
their ratings, resolve any disagreements,
and devise a consensus rating.

n n n Complete the scoresheets

Tally the item scores and determine
the level of implementation achieved.

Evaluating Your Program 13 Monitor Outcomes

Evaluating Your Program

Monitor Outcomes

Unlike process measures, which must be
used in full to comprehensively understand
how services are provided, you must
decide which outcome measures will be
most informative for your program.
Initially, your outcomes monitoring system
should be simple to use and maintain.
Complexity has doomed many well-
intended attempts to collect and use
outcomes data.

One way to simplify is to limit the number
of outcome measures. Select your outcome
measures based on the

type of information that will be most useful
to your agency. Based on the research
literature, we suggest that you monitor a
core set of outcomes such as the following:

n Relapse and hospitalization;

n Family well-being;

n Participation in

Supported Employment

or vocational rehabilitation;

n Employment rates; and

n Cost of care.

Monitor Outcomes 14 Evaluating Your Program

These few outcomes reflect the primary goals
of FPE. Specifically, the goal of FPE is to help
consumers move forward in the process of
recovering from mental illnesses and pursuing
meaningful life goals. For this reason, it is
important for you to capture outcomes for recovery
in a way that is most useful for your program.

For data to be useful, they must be valid. That is,
the data must measure what they are supposed
to measure. Thus, the outcomes must be few and
concrete for FPE practitioners to focus on key
outcomes, to understand them in a similar way,
and to make their ratings in a consistent and error-
free fashion.

To enhance validity, we recommend using simple
ratings initially. Limiting your outcome measures
to concrete measures will also allow you to collect
data from FPE practitioners.

Develop procedures

Agencies may choose either to develop the outcomes
portion of their quality assurance system from
scratch or to use existing outcomes monitoring
systems. A number of electronic evaluation
programs are available to help you develop
comprehensive, integrated, user-friendly outcome
monitoring systems. Examples include the following:

n Publicly available tools such as the Consumer
Outcomes Monitoring Package (see box
below), the Decision Support 2000+ Online
(http://www.ds2kplus.org); or

n Various commercially available products.

What Is the Consumer Outcomes Monitoring Package?

Sponsored in part by the Substance Abuse and
Mental Health Services Administration (SAMHSA),
the Consumer Outcomes Monitoring Package
(COMP) was designed by a team at the School of
Social Welfare, University of Kansas. This computer
application allows agencies to choose from a pre-
established list of outcomes developed for each
evidence-based practice. Data may be entered
for the chosen outcomes, and reports can be
generated quarterly or monthly. The COMP also
allows agencies to view their outcomes data using
a variety of tables and graphs.

The designers of COMP tried to make the
computer application as easy and as flexible

to use as possible. You may access COMP through
the Web. Agencies can download the computer
application and print out Installation Instructions
and a User Manual, which provides definitions
and forms.

To download COMP

n Go to http://research.socwel.ku.edu/ebp.

n Click on the link to the download page.

n Click on the links to download the Installation
Instructions and User Manual.

n Follow the instructions to install the application.

http://www.ds2kplus.org

http://research.socwel.ku.edu/ebp

Evaluating Your Program 15 Monitor Outcomes

When deciding whether to use an existing
outcomes monitoring package or to design your
own, it is important to keep your agency’s
capabilities in mind. The system must not create
undue burden for FPE practitioners, and it must
give them information that is useful in their jobs.

The system should fit into the workflow of the
agency, whether that means making ratings on
paper, using the COMP computer application, or
developing your own outcomes monitoring package.

Start with whatever means are available and expand
the system from there. In the beginning, you may
collect data with a simple report form and you can
report hand-tallied summaries to FPE practitioners.

Computer software that allows for data entry
and manipulation (for example, Microsoft Access,
Excel, and Lotus) makes tabulating data and
graphing easier than doing them by hand. A
computerized system for data entry and report
generation presents a clear advantage and it may
be the goal, but do not wait for it. Feedback does
not have to come from a sophisticated computer
system to be useful. It is more important that it is
meaningful and frequent. For a sample Outcomes
Report Form, see Appendix G, which is an
example of a simple, paper-based way to collect
participation and outcomes data regularly. For
instructions for using the Outcomes Report Form,
see Appendix H.

Expanding Your Outcome Measures

Once you have established your core outcomes
monitoring system, have learned how to routinely
collect data, and are accustomed to using it to
improve your FPE program, you will be ready
to expand your outcomes measures.

Consider asking consumers and families for input
about how to improve your FPE program, both
practically and clinically. Consumers and families are
important informants for agencies that are seeking
to improve outcomes. Agencies may want to know
the following:

n If consumers and families are satisfied with their
services;

n How services have affected their quality of life;
and

n Whether consumers believe the services are
helping them achieve their recovery goals.

While collecting data from consumers and families
requires more staff time than the information that
may be reported quickly by FPE practitioners,
consumers and families can give valuable feedback.

We recommend the following surveys for collecting
information from consumers and families:

n The Mental Health Statistics Improvement
Program (MHSIP) Consumer Satisfaction Survey
at http://www.mhsip.org

n Recovery measurement instruments such as
those described in Measuring the Promise: A
Compendium of Recovery Measures, Volume II,
available through http://www.tecathsri.org

It is difficult to get a representative sample
of consumer and family respondents since
mailed surveys are often not returned and
interviews may only be done with people who
are cooperative and easy to reach. Samples that
are not representative may be biased.

Avoid bias in your consumer and family data by
using a variety of mechanisms to conduct your
assessments. For example, consider combining
feedback collected through surveys with that
obtained from focus groups. Another option is to
hire a consultant to conduct qualitative interviews
with a small group of consumers or families.

http://www.mhsip.org

http://www.tecathsri.org

Monitor Outcomes 16 Evaluating Your Program

How often should you collect
outcomes data?

Plan to monitor the outcomes for consumers in
your FPE program every 3 months and share the
data with program staff. Collecting data at regular
and short intervals will enhance the reliability of
your outcomes data.

While we recommend that you design a system for
collecting outcomes early in the implementation
process, FPE programs should not expect to see
the desired results until the program is fully
operational. Depending on resources available to
your program, this may take anywhere from 6 to 18
months to accomplish.

How should you identify data collectors?

Agency administrators or mental health authorities
may assign the responsibility for collecting
outcomes data to the following:

n The family intervention coordinator;

n Members of the FPE Advisory Committee;

n The quality assurance team;

n Independent consultants, including consumers
and family members; and

n Other staff.

Unlike collecting process measures, collecting
outcome measures does not require a day-long
assessment process. Many standard outcome
measures will be information that FPE
practitioners can report from their daily work
with consumers.

It is important to develop a quick, easy, standardized
approach to collect outcomes data. For example,
create a simple form or computer database that
FPE practitioners can routinely update.

Evaluating Your Program 17 Use Data to Improve Your Program

Evaluating Your Program

Use Data to Improve Your Program

As you develop a quality assurance system,
family intervention coordinators and FPE
practitioners will weave it into the fabric
of their daily routines. Process assessments
will give you a window into the demanding
work done every day. Outcome reports will
give you tangible evidence of the use and
value of services, and they will become a
basis for decisionmaking and supervision.

At some point, your program staff may
wonder how they did their jobs without
an information system. They will come to
view it as an essential ingredient of well-
implemented evidence-based practices.

Use Data to Improve Your Program 18 Evaluating Your Program

n n n Create reports from your assessments

For your process data, in addition to
completing the FPE Fidelity Scale,
General Organizational Index, and
scoresheets, assessors should write a report
explaining their scores. The report should
include the following:

n An interpretation of the results of the
assessment;

n Strengths and weaknesses of the FPE
program; and

n Clear recommendations to help the
program improve.

The report should be informative, factual,
and constructive. Since some process
measures assess adherence to the
evidence-based model at both the agency
and program staff levels, remember
to target recommendations to
administrators, the family intervention
coordinator, and FPE practitioners.

When summarizing outcomes data, start
with simple, easy-to-read reports. Then let
experience determine what additional
reports you need. You can design your
reports to give information about individual
consumers, a single FPE practitioner’s
caseload, or the program as a whole. For
example, reports generated for individual
consumers may track the consumer’s
participation in specific stages of treatment
and outcomes over time. You could enter
these reports in consumers’ charts, and they
could be the basis for discussions about
consumers’ progress.

n n n Use tables and graphs to understand
your outcomes data

After the first process and outcomes
assessments, it is often useful to provide
a visual representation of a program’s
progress over time. We recommend that
you use tables and graphs to help
understand and report the results.

By graphing your fidelity score, you have a
visual representation of how your program
has changed over time. For an example, see
Figure 1. For your process data, you may
simply graph the results using a spreadsheet
and include this in your report.

When your program shows greater fidelity
over time, the graph will display it and
reinforce your efforts. Additionally, as you
can see in Figure 1, the graph allows you
to quickly compare one team to another.
In this example, Team A struggled in the
first 6 months. Understanding Team A’s
progress compared to Team B’s allowed
the teams to partner and share strategies.
Consequently, Team A improved
dramatically over the next 6-month period.

Another feature of graphing assessment
scores is to examine the cut-off scores for
fair (52) or good (62) implementation. Your
program can use these scores as targets.

Evaluating Your Program 19 Use Data to Improve Your Program

Figure 1. Fidelity Over Time

70

80

90

100

1

10

120

130

140

▲

▲
▲
▲
▲

■

■
■

■
■

■▲

Team A

Team B

Date of Assessment

Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct
2006

2007

Note: 62 – 70 = good implementation

52 – 61 = fair implementation

51 and below = not evidence-based practice

Here are three examples of tables and graphs
that can help you understand and use your
outcomes data.

Example 1: Periodic summary tables

Periodic summary tables summarize your
outcomes data each quarter and address these
kinds of questions:

n How many consumers participated in our FPE
program during the last quarter?

n What proportion of consumers in our FPE
program were hospitalized last quarter?

n How did the hospitalization rate for those
participating in FPE compare to the rate for
consumers in standard treatment?

Agencies often use this type of table to understand
consumer participation or to compare actual
results with agency targets or goals. These tables
are also frequently used to describe agencies’

services in annual reports or for external
community presentations.

Table 1: Sample Periodic Summary Table of Enrollment
in Evidence-Based Practices

Not
eligible

Eligible but
NOT in EBP
service

Enrolled Percent
of eligible
consumers
enrolled

Family
Psychoeducation

0 30 60 67%

Assertive
Community
Treatment

30 25 90 78%

This agency provided both Family Psychoeducation
(FPE) and Assertive Community Treatment (ACT).
The FPE staff identified 90 consumers for the
program. Of those, 60 received FPE, while 30
consumers were eligible but received another
service. Consequently, 67 percent of consumers
who were eligible for the FPE program participated
in the program.

Use Data to Improve Your Program 20 Evaluating Your Program

Example 2: Movement tables

Tables that track changes in consumer
characteristics (called movement tables) can give
you a quick reference for determining service
effectiveness. For example, Table 2 compares
consumers’ residential status between two quarters.

Table 2: Sample Movement Table

To FY ’06 Qtr 3

From:
FY ‘06
Qtr:

2

Institutional Substantial
care

Semi-
independant

Independant Total

Institutional 2 1 1 3 7

Substantial care 3 8 1 3 15

Semi-
independant 1 0 2 4 7

Independant 1 3 2 100 10

6

Total 7 12 6 110 135

To create this table, the data were collapsed into
the four broad categories. The vertical data cells
reflect the residential status for consumers for
the beginning quarter. The horizontal data cells
reflect the most recent quarterly information.
The residential status categories are then ordered
from the most restrictive setting (institutional)
to the least restrictive (independent).

The data in this table are presented in three colors.
The purple cells are those above the diagonal, the
blue cells are those below the diagonal, and the
white cells are those within the diagonal. The data
cells above the diagonal represent consumers who
moved into a less restrictive environment between
quarters. As you can see, one consumer moved
from institutional to substantial care, one to semi-
independent care, and three to independent living.
Furthermore, one consumer moved from

Above the diagonal

Below the diagonal

Within the diagonal

substantial care to semi-independent care, three
consumers moved from substantial care to
independent care and four consumers moved
from semi-independent care to independent care.
These 13 consumers (10 percent of the 135
consumers in the program) moved to a more
desirable stage of treatment between quarters.

The data reported in the diagonal cells ranging
from the upper left quadrant to the lower right
reflect consumers who remained in the same
residential status between quarters. Two
consumers were in an institution for both quarters
of this report; eight remained in substantial care,
two in semi-independent and 100 in independent
living. These 112 consumers (83 percent of the 135
consumers in the program) remained stable
between quarters.

Evaluating Your Program 21 Use Data to Improve Your Program

The cells below the diagonal line represent
consumers who moved into a more restrictive
setting between quarters. Three consumers moved
from substantial to institutional care, one consumer
moved from semi-independent care to institutional
care, one consumer moved from independent
living to institutional care, three moved from
independent living to substantial care, and
two moved from independent living to semi-
independent care. These 10 consumers (7 percent
of the 135 consumers in the program) experienced
some setbacks between quarters. The column
totals show the number of consumers in a given
residential status for the current quarter, and the
row totals show the prior quarter.

You can use movement tables to portray changes
in outcomes that are important to consumers,
supervisors, and policymakers. The data may
stimulate discussion about the progress that
consumers are making or the challenges with
which they are presented.

Example 3: Longitudinal plots

A longitudinal plot is an efficient and informative
way to display participation or outcomes data for
more than two successive periods. The goal is to
view performance in the long term. You can use
a longitudinal plot for a consumer, a caseload,
a specific evidence-based practice, or an entire
program. A single plot can also contain longitudinal
data for multiple consumers, caseloads, or programs
for comparison. Figure 2 presents an example of a
longitudinal plot comparing critical incidents for one
FPE program over an 11-month period.

This plot reveals that with the exception of private
psychiatric hospitalizations, all other critical
incidents appear to be going in a positive direction
(that is, there is a reduction in incidence).

Longitudinal plots are powerful feedback tools
because they permit a longer range perspective
on participation and outcome, whether for a single

consumer or a group of consumers. They enable a
meaningful evaluation of the success of a program,
and they provide a basis for setting goals for future
performance.

n n n Share your results

The single factor that will most likely
determine the success of a quality
assurance system is its ability to give useful
and timely feedback to key stakeholders.
It is fine to worry about what to enter into
a system, but ultimately its worth is in
converting data into meaningful
information. For example, data may show
that 20 consumers were homeless during
the past quarter, but it is more informative
to know that this represents 10 percent
of the consumers in the FPE program.

For information to influence practice, it
must be understandable and meaningful,
and it must be delivered in a timely way.

Figure 2. Sample Longitudinal Plot for Monthly Frequency
of Negative Incidents for Consumers

◆

✖

✖
✖
✖
✖
✖
✖

✖
✖

✖
✖
✖

▲ ▲

▲
▲

▲
▲
▲
▲
▲
▲
▲

◆
◆

◆
◆◆

◆
◆
◆
■

■
■■

■
■
■
■
■

■
■◆ ◆

◆

Homeless

Incarcerated

In-Patient substance abuse

Priv. Psych. Hosp.

■
▲

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

2007

16

1

4

12

10

8

6
4
2
0

Use Data to Improve Your Program 22 Evaluating Your Program

In addition, the quality assurance system
must tailor the information to suit the
needs of various users and to answer
their questions.

Sharing results with FPE practitioners

After each assessment, dedicate time
during a supervisory meeting to discuss
the results. Numbers that reflect above
average or exceptional performance should
trigger recognition, compliments, or other
rewards. Data that reflect below average
performance should evoke a search for
underlying reasons and should generate
strategies that offer the promise of
improvement. By doing this regularly, the
family intervention coordinator will create
a learning organization characterized by
adaptive responses to information that aim
to improve consumer outcomes.

Sharing results with your FPE Advisory
Committee or quality assurance team

You may also use this information to keep
external stakeholders engaged. Sharing
information with vested members of the
community, staff from your mental health
authority, and consumers and family
advocates can be valuable. Through these
channels, you may develop support for
the FPE program, increase consumer
participation, and raise private funds
for your agency.

Sharing results internally

Agencies may distribute reports during
all staff and manager-level meetings to
keep staff across the agency informed and
engaged in the process of implementing
your FPE program. Agencies with
successful FPE programs highlight the
importance of developing an
understanding and support for the
evidence-based model across the agency.

Additionally, integrating consumer-specific
reports into clinical charts may help you
monitor consumers’ progress over time.
Reporting consumer-specific outcomes
information at the treatment team meetings
also helps keep the team focused on
consumers’ goals.

Sharing results with consumers
and families

Agencies may highlight assessment results
in consumer and family meetings.
Increasing consumers’ and families’
understanding of the FPE program may
motivate them to participate in the
treatment process and build trust in the
consumer-provider relationship.

Also, sharing results may create hope
and enthusiasm for your FPE program.
Sharing information motivates people and
stimulates changes in behavior. Sharing the
results of your assessments with a variety
of stakeholders is the key to improving
your program.

Evaluating Your Program 23 Appendix A: Cover Sheet

Evaluating Your Program

Appendix A: Cover Sheet—

Family Psychoeducation Fidelity Scale

and General Organizational Index

Evaluating Your Program 25 Appendix A: Cover Sheet

Cover Sheet: Family Psychoeducation Fidelity Scale
and General Organizational Index

Today’s date

Assessors’ names

Program name (or Program code)

Agency name

Agency address
Street

City State ZIP code

Family intervention coordinator or contact person

Names of FPE practitioners

Telephone E-mail

Sources used for assessments: q Chart review: Number reviewed
q FPE multifamily group observation

q Planning and supervisory meeting observation
q Family intervention coordinator interview
q FPE practitioner interviews Number interviewed
q Consumer interviews Number interviewed
q Family member interviews Number interviewed
q Other staff interviews Number interviewed
q Brochure review
q Other

Number of FPE practitioners

Number of consumers/families in the program

Number of consumers/families who left the program in the past 6 months

Number of consumers/families served in the past 6 months

Funding source

Agency location: q Urban
q Rural

Date program was started

( ) –

/ /

/ /

Evaluating Your Program 27 Appendix B: Checklist

Evaluating Your Program

Appendix B: Checklist—
Observation of Multifamily Group Sessions

Evaluating Your Program 29 Appendix B: Checklist

Checklist—Observation of Multifamily Group Sessions

Today’s date
Assessors’ names

Program name (or Program code)
Agency name
Agency address
Street

City State ZIP code

Names of FPE practitioners

Number of consumer participants

Number of family participants

Frequency of sessions

Item 11. Structured Group Sessions

Yes No

1. Beginning socialization q q
2. Review progress from last session’s action plan q q
3. Go-round q q
4. Selection of a single problem q q
5. Structured problem-solving q q
6. End with socialization q q

Rating

Item 12. Structured Problem-Solving Technique

Yes No

1. Define the problem

2. Generate solutions

q q
q q

3. Discuss advantages and disadvantages of each solution

4. Choose the best solution

q q
q q

5. Form an action plan

6. Review the action plan

q q
q q

Rating
/ /

Evaluating Your Program 31 Appendix C: Fidelity Scale and Score Sheet

Evaluating Your Program

Appendix C: Family Psychoeducation Fidelity Scale
and Score Sheet

Evaluating Your Program 33 Appendix C: Fidelity Scale and Score Sheet

Family Psychoeducation Fidelity Scale

Criteria

Ratings / Anchors

1 2 3 4 5

1. Family intervention coordinator:

Designated clinical administrator
who performs the following tasks:

n Establishes, monitors, and
automates family intake and
engagement procedures

n Assigns potential FPE
consumers to FPE practitioners

n Monitors and adjusts FPE
practitioner caseloads

n Arranges for training new FPE
practitioners and continuing
education of existing FPE staff

n Supervises FPE staff

Agency does not
have a designated
staff member

OR

Cannot rate due
to no fit.

Agency has a
designated staff
member who
performs 1 or 2
of the tasks.

Agency has a
designated staff
member who
performs 3 of
the tasks.

Agency has a
designated staff
member who
performs 4 of
the tasks.

Agency has a
designated staff
member who
performs all tasks.

2. Session frequency:

Families and consumers
participate biweekly in FPE
sessions.

< Every 3 months

OR
Cannot rate due
to no fit.

Every 3 months Every 2 months Monthly At least twice
a month

3. Long-term FPE:

Families and consumers are
provided with long-term
FPE; specifically, at least one
family member per consumer
participates in FPE sessions for
at least 9 months.

Most families and
consumers receive
less than 6 months
of FPE sessions

OR
Cannot rate due
to no fit.

Most families and
consumers receive
6–7 months of FPE
sessions.

Most families and
consumers receive
7–8 months of FPE
sessions.

Most families and
consumers receive
8–9 months of FPE
sessions.

More than 90%
of families and
consumers receive
at least 9 months
of FPE sessions.

4. Quality of practitioner-
consumer-family alliance

FPE practitioners engage family
members and consumers with
warmth, empathy, acceptance,
and attention to each individual’s
needs and desires.

High dropout rate

OR

Cannot rate due
to no fit.

Sources indicate
that alliance is often
poor, leading to high
dropout rate.

MSources indicate
alliance is
inconsistent or barely
adequate, leading to
moderate dropout
rate,

OR

Information is
inconsistent

Sources indicate a
fairly strong alliance.

Sources consistently
indicate a strong
alliance.

5. Detailed family reaction:

FPE practitioners identify and
specify the family’s reaction to
their relative’s mental illnesses.

There is consistent
evidence for less
than 33% of
involved families.

There is consistent
evidence for
33–49% of involved
families.

There is consistent
evidence for
50–64% of involved
families.

There is consistent
evidence for
65–79% of involved
families.

There is consistent
evidence for 80%
or more of involved
families.

6. Precipitating factors:

FPE practitioners, consumers,
and families identify and specify
precipitating factors for the
consumers’ mental illnesses.

There is consistent
evidence for less
than 33% of
involved families
and consumers.

There is consistent
evidence for 33-49%
of involved families
and consumers.

There is consistent
evidence for
50–64% of involved
families and
consumers.

There is consistent
evidence for
65–79% of involved
families and
consumers.

There is consistent
evidence for 80%
or more of involved
families and
consumers.

7. Prodromal signs
and symptoms:

FPE practitioners, consumers,
and families identify and specify
prodromal signs and symptoms
of the consumer’s mental illnesses.

There is consistent
evidence for less
than 33% of
involved families and
consumers.

There is consistent
evidence for
33–49% of involved
families and
consumers.

There is consistent
evidence for
50–64% of involved
families and
consumers.
There is consistent
evidence for
65–79% of involved
families and
consumers.

There is consistent
evidence for 80%
or more of involved
families and
consumers.

Appendix C: Fidelity Scale and Score Sheet 34 Evaluating Your Program

Family Psychoeducation Fidelity Scale

Criteria
Ratings / Anchors
1 2 3 4 5

8. Coping strategies:

FPE practitioners identify,
describe, clarify, and teach coping
strategies.

There is consistent
evidence for less
than 33% of
involved families and
consumers.

There is consistent
evidence for
33–49% of involved
families and
consumers.

There is consistent
evidence for
50–64% of involved
families and
consumers.
There is consistent
evidence for
65–79% of involved
families and
consumers.
There is consistent
evidence for 80%
or more of involved
families and
consumers.

9. Educational curriculum:

FPE practitioners use a
standardized curriculum to teach
families about mental illnesses.
The curriculum covers six topics:

n Psychobiology of the specific
mental illness;

n Diagnosis;

n Treatment and rehabilitation;

n Impact of mental illness
on the family;

n Relapse prevention; and

n Family guidelines.

Less than 33%
of involved
families receive
a standardized
educational
curriculum, no
standardized
educational
curriculum exists,

OR

Only 1–2 topics
are covered

33–49% of involved
families receive
a standardized
educational
curriculum covering
all 6 topics

OR

Only 3 topics
are covered.

50–64% of involved
families receive
a standardized
educational
curriculum covering
all 6 topics

OR

Only 4–5 topics
are covered.

65–79% of involved
families receive
a standardized
educational
curriculum covering
all 6 topics.

80% or more
of involved
families receive
a standardized
educational
curriculum covering
all 6 topics.

10. Multimedia education:

Consumers and family members
are given educational materials
about mental illnesses in several
formats (for example, paper,
video, and Web sites).

Less than 33%
of families and
consumers receive
educational materials

OR
Cannot rate due
to no fit.

33–49% of families
and consumers
receive educational
materials

OR

Materials are given
in only 1 format.

50–64% of families
and consumers
receive educational
materials

OR

Materials are given
in only 2 formats.

65–79% of families
and consumers
receive educational
materials in all 3
formats.

80% or more
of families and
consumers receive
educational materials
in all 3 formats.

11 Structured group sessions:

FPE practitioners follow a
structured procedure that includes
the following:

n Beginning socialization;

n Review progress from last
session’s action plan;

n Go-round;

n Selection of a single problem;

n Structured problem solving;
and

n Ending with socialization.

Groups include 2 or
fewer components.

Groups include 3 of
the 6 components.

Groups include 4 of
the 6 components.

Groups include 5 of
the 6 components.

Groups include all
6 components.

Evaluating Your Program 35 Appendix C: Fidelity Scale and Score Sheet

Family Psychoeducation Fidelity Scale

Criteria
Ratings / Anchors
1 2 3 4 5

12. Structured problem–solving:

FPE practitioners use a
standardized approach to help
consumers and families with
problem solving, which includes
the following:

n Define the problem;

n Generate solutions;

n Discuss the advantages and
disadvantages of each solution;

n Choose the best solution;

n Form an action plan; and

n Review the action plan.

No more than 2 of
6 components of the
structured problem-
solving are used.

3 of 6 components
of the structured
problem-solving
are used.

4 of 6 components
of the structured
problem-solving
are used.

5 of 6 components
of the structured
problem-solving
are used.

All 6 components
of the structured
problem-solving
are used.

13. Stage-wise provision
of services:

FPE services are provided
in the following:

n Engagement;

n 3 or more joining sessions;

n Educational workshop; and

n Multifamily group.

Families and
consumers begin
multifamily groups
with minimal or
no engagement,
no joining sessions,
or no education.

Engagement is
minimal and only
1 joining session is
completed before
entry into the
multifamily group.
Education is delayed
or absent.

Engagement and
2 joining sessions
are completed
before entry into the
multifamily group.
Education is delayed
or absent.

Most steps are
done in order;
however, families
enter multifamily
groups before 3
joining sessions
are completed
or education is
provided.

Engagement, all
3 joining sessions,
and education are
completed before
entry into the
multifamily group.

14. Assertive engagement
and outreach:

FPE practitioners assertively
engage all potential consumers
and family members by phone,
by mail, or in person (in the
agency or in the community)
on an ongoing basis.

FPE practitioners do
not engage potential
consumers and
family members.

FPE practitioners
engage potential
consumers and
family members
only once as part of
initial engagement.

FPE practitioners
engage potential
consumers and
family members
2 times as part of
initial engagement.

FPE practitioners
assertively engage
some potential
consumers and
family members
using all necessary
means on a time-
limited basis.

FPE practitioners
assertively engage all
potential consumers
and family members
using all necessary
contact means on an
ongoing basis.

FPE practitioners
demonstrate
tolerance of different
levels of readiness
using gentle
encouragement.

Appendix C: Fidelity Scale and Score Sheet 36 Evaluating Your Program

Score Sheet: Family Psychoeducation Fidelity Scale

Date of visit

Agency name

Assessors’ names

Assessor 1 Assessor 2 Consensus

1 Family intervention coordinator

2 Session frequency

3 Long-term FPE

4 Quality of practitioner-consumer-family alliance

5 Detailed family reaction

6 Precipitating factors

7 Prodromal signs and symptoms

8 Coping strategies

9 Educational curriculum

10 Multimedia education

11 Structured group sessions

12 Structured problem-solving

13 Stage-wise provision of services

14 Assertive engagement and outreach

Total score

Items not rated

62-70 = Good implementation

52-61 = Fair implementation
51 and below = Not evidence-based practice

/ /

Evaluating Your Program 37 Appendix D: Fidelity Scale Protocol

Evaluating Your Program

Appendix D: Family Psychoeducation
Fidelity Scale Protocol

Evaluating Your Program 39 Appendix D: Fidelity Scale Protocol

Family Psychoeducation Fidelity
Scale Protocol

This protocol explains how to rate each item on
the FPE Fidelity Scale. In particular, it provides
the following:

n A definition and rationale for each fidelity
item. These items have been derived from
comprehensive, evidence-based literature.

n A list of data sources most appropriate for
each fidelity item (for example, chart review,
family intervention coordinator interview, FPE
practitioners, consumers, or families). When
appropriate, a set of probe questions is provided
to help you elicit the critical information
needed to code the item. These questions
were specifically generated to help you collect
information from respondents that is free from
bias such as social desirability.

n Decision rules that will help score each item
correctly. As you collect information from various
sources, these rules will help you determine the
specific rating to give for each item.

1. Family intervention coordinator

Definition: One clinical administrator is designated to
oversee the FPE program for a substantial
portion of the job (time depends on size of
program). This person’s role includes
activities such as the following:

n Establishing, monitoring, and automating
family intake and engagement
procedures;

n Assigning potential FPE consumers
to FPE practitioners;

n Monitoring and adjusting FPE
practitioners’ caseloads;

n Arranging for training of new staff
and continuing education of existing
FPE staff;

n Supervising FPE practitioners.

Rationale: Delivery of services to families must be
subject to accountability and tracking. One
effective way for agencies to monitor the
delivery of family services is to create a
position of family intervention coordinator,
who would also serve as the contact person
for FPE services, facilitate communication
between staff and families, and supervise
FPE practitioners.

Sources of information: Before the site visit, determine
whether the organization has someone who
has a title of family intervention coordinator
or its equivalent. During the fidelity visit,
interview the agency director, family
intervention coordinator, practitioners,
consumers, and family members.

Item response coding: The agency director and family
intervention coordinator are the primary sources of
information for this item. If other sources do not report
these responsibilities performed by the coordinator, then
fidelity assessors should follow up with the agency
director and family intervention coordinator with
clarifying questions and documentation (at end of the
fidelity visit day or in follow-up call). If the program does
not have a designated position of family intervention
coordinator (or an equivalent), code the item as “1.”
If the program has a designated staff member who
performs all five tasks, code the item as “5.”

Probe questions

For family intervention coordinators:

n “What is your role in the FPE program? How
much time do you devote to this? What kinds
of responsibilities do you have?” [Check who
performs the tasks specified above.]

n “Can you explain intake procedures, monitoring,
training schedule, and supervision schedule?”

For FPE

practitioners:

n “What functions does the family intervention
coordinator perform?”

n [Read list of five tasks listed above.] “Is anyone
responsible for these tasks?”

For consumers and family members: “What
functions does [family intervention coordinator’s
name] perform?”

Appendix D: Fidelity Scale Protocol 40 Evaluating Your Program

2. Session frequency

Definition: Families and consumers participate at least
in biweekly FPE sessions.

Rationale: It is presumed that families benefit more if
sessions are offered regularly and predictably.

Sources of information: Chart review, roster of sessions,
and interviews with family intervention
coordinator, FPE practitioners, consumers,
and family members.

Item response coding: The primary evidence for coding
this item would be attendance rosters or a calendar of
scheduled events, if such documents exist. The
program should have some way of documenting the
frequency of FPE sessions. If the documentation
suggests that the organization provides at least
biweekly FPE sessions, code the item as “5.”

Probe questions
For family intervention coordinators:

n “How often are FPE sessions held for family
members?”

n “Do you have attendance rosters, a calendar of
events, or other documentation to verify this?”

For FPE practitioners:
n “How often are FPE sessions held for family
members?”
n “Do you have attendance rosters, a calendar of
events, or other documentation to verify this?”

For consumers and family members: “How often
are FPE sessions held for family members?”

3. Long-term FPE

Definition: Families and consumers are provided with
long-term FPE; specifically, at least one
family member per consumer participates
in FPE sessions for at least 9 months.

Rationale: In general, 9 months of biweekly equivalent
FPE sessions are required for families
and consumers to learn the necessary
information and problem-solving skills.
After completing the program, families and
consumers may also benefit from booster
sessions or support groups.

Sources of information: Chart review, roster of sessions,
and interviews with the family intervention
coordinator, FPE practitioners, consumers,
and family members.

Item response coding: The primary evidence for coding
this item would be a report containing the number of
families and consumers completing FPE and how long
they attended, records of duration of FPE groups, or
attendance sheets. In the absence of written records,
the assessment will depend on interviews. Excluding
dropouts, if there is evidence that 90 percent or less of
families receive at least 9 months of FPE sessions,
code the item as “5.”

Probe questions

For family intervention coordinators or FPE practitioners:

n “How long do family members attend FPE
before they graduate?”

n “Do you have attendance rosters, a calendar of
events, or other documentation to verify this?”

For consumers and family members:

n “How long have you attended FPE sessions?”

n “How long do you intend to attend?”

Evaluating Your Program 41 Appendix D: Fidelity Scale Protocol

4. Quality of Practitioner-Consumer-
Family Alliance

Definition: FPE practitioners engage family members
and consumers with warmth, empathy,
acceptance, and attention to each
individual’s needs and desires.

Rationale: When the alliance between practitioners,
consumers, and families is poor, family
members and consumers are less likely to
participate fully or at all in FPE programs
and, as a result, are less likely to benefit
from FPE services.

Sources of information: Interviews with FPE
practitioners, family members, and
consumers. Observations of FPE sessions.

Item response coding: The primary source for rating this
item is direct observation. This item requires clinical
judgment and is based on the fidelity assessor’s
experience. Negative indicators would include
comments in interviews, FPE sessions, or charts
expressing judgmental or blaming attitudes. If sources
consistently indicate a strong alliance for all FPE
practitioners, code the item as “5.”

Probe questions
For FPE practitioners:

n “How do you establish rapport or develop an
alliance with family members and consumers?”

n “How would you rate or describe your alliance
with [family and consumer’s name]?” [Select one
family and consumer with whom the practitioner
works.]

n “Are there any family members or consumers
with whom you feel your relationship is
counterproductive or poor?”

For family members and consumers:

n “How would you describe your relationship with
[FPE practitioner’s name]?”

n “Do you feel that [FPE practitioner’s name] has
worked to establish a good relationship with you?
What has he or she done to connect with you?
What has he or she done that makes it more
difficult for you to work with him or her?”

n “What would you change about your working
relationship with [FPE practitioner’s name] to
make it better?”

Appendix D: Fidelity Scale Protocol 42 Evaluating Your Program

5. Detailed Family Reaction

Definition: FPE practitioners identify and specify the
family’s reaction to their relative’s mental
illnesses. Reactions are emotional and
behavioral responses (note the distinction
from coping strategies in Item 8).

Rationale: A core principle of FPE is to help family
members achieve a basic understanding of
serious mental illnesses as well as to resolve
family conflict by listening and responding
sensitively to each family’s emotional
distress related to having a relative with
serious mental illnesses.

Sources of information: Chart review (especially
treatment plan) and interviews with FPE
practitioners, consumers, and families.

Item response coding: If documentation in the treatment
plan and reports by FPE practitioners, consumers, and
families corroborate that family reactions are identified
and specified in joining sessions for 80 percent or more
of involved families, code the item as “5.”

Probe questions

For practitioners:

n “What sorts of issues do you discuss in joining
sessions?”

n “Do you address how families react emotionally
or behaviorally to their relatives’ mental illnesses?”

n “What sorts of activities do you engage in to help
them deal with their reactions?”

n Using a chart for a family member seen by the
practitioner, ask the practitioner to explain the
specifics.

For consumers and family members:

n “What sorts of issues did you discuss during the
first couple of FPE sessions?”

n “Earlier in the FPE sessions, did you spend time
discussing how you felt and reacted about the
illness?”

n “Did the practitioner lead you in activities to
help you deal with your feelings and reactions?”

6. Precipitating Factors

Definition: FPE practitioners, consumers, and families
identify and specify precipitating factors for
consumers’ mental illnesses.

Rationale: Exploring factors that have precipitated
relapse in the past is a crucial step to
developing individualized relapse
prevention and illness management
strategies. Involving consumers and families
as equal partners in planning and delivering
treatment is a core principle of FPE.

Sources of information: Chart review (especially
treatment plan) and interviews with FPE
practitioners, consumers, and families.

Item response coding: If documentation in the treatment
plan and reports by FPE practitioners, consumers,
and families corroborate that precipitating factors
are identified and specified in joining sessions for 80
percent or more of involved families and consumers,
code the item as “5.”

Probe questions

For FPE practitioners:

n “In joining sessions, do you discuss the
precipitating factors of the illness with families
and consumers?” [If yes, “Can you describe the
process you use to discuss them? Can you show
me examples?”]

n Using a chart, ask the FPE practitioner
to explain the specifics.

For consumers and family members:

n “Earlier in the FPE sessions, did the FPE
practitioner identify precipitating factors for
[your or your relative’s] illness?” [If yes, “Please
give examples.”]

n “Did you discuss how to respond to them once
you notice these factors? Have you reviewed
these strategies in later sessions?”

Evaluating Your Program 43 Appendix D: Fidelity Scale Protocol

7. Prodromal Signs and Symptoms

Definition: FPE practitioners, consumers, and families
identify and specify prodromal signs and
symptoms of consumers’ mental illnesses.

Rationale: Exploring consumers’ prodromal signs
and symptoms is another crucial step
to developing individualized relapse
prevention and illness management
strategies. Involving consumers and families
as equal partners in planning and delivering
treatment is a core principle of FPE.

Sources of information: Chart review (especially
treatment plan) and interviews with FPE
practitioners, consumers, and families.

Item response coding: If documentation in the treatment
plan and reports by FPE practitioners, consumers,
and families corroborate that prodromal signs and
symptoms are identified and specified in joining
sessions for 80 percent or more of involved families,
code the item as “5.”

Probe questions
For FPE practitioners:

n “In joining sessions, do you identify prodromal
symptoms with consumers and families?”
[If yes, “Can you describe the process you use
to identify them? Can you give an example?”]

n Using a chart, ask the practitioner to explain
the specifics.

For consumers and family members:

n “Earlier in the FPE sessions, did the FPE
practitioner discuss the signs that you (or your
family member) may be becoming symptomatic?”

n “What sorts of things were suggested in your
sessions for recognizing the early signs and
symptoms of the illness? Please give examples.
Have you reviewed these suggestions in later
sessions?”

8. Coping Strategies

Definition: FPE practitioners identify, describe, clarify,
and teach coping strategies. Coping
strategies are intentional and thoughtful
attempts to change behavior or symptoms
related to mental illnesses (note the
distinction from family reactions in Item 5).

Rationale: Exploring coping strategies that have
and have not worked is a crucial step
to developing individualized relapse
prevention and illness management
strategies. Insight into patterns of
ineffective interactions and behaviors is
likely to motivate consumers and families
toward desired change.

Sources of information: Chart review (especially
treatment plan) and interviews with FPE
practitioners, consumers, and families.

Item response coding: If documentation in the treatment
plan and reports by FPE practitioners, consumers, and
families corroborate that practitioners help 80 percent
or more of involved families and consumers to identify,
describe, clarify, and learn coping strategies in joining
sessions, code the item as “5.”

Probe questions
For FPE practitioners:

n “Do you identify coping strategies with
consumers and families?” [If yes, “Can
you describe the process you use?”]

n Using a chart, ask the FPE practitioner
to explain the specifics.
For consumers and family members:

n “Have you discussed coping strategies?
What sorts of things did you talk about?”

n “Did you discuss alternative ways of coping
with [your or your relative’s] illness?”

Appendix D: Fidelity Scale Protocol 44 Evaluating Your Program

9. Educational Curriculum

Definition: FPE practitioners use a standardized
curriculum to teach families about mental
illnesses. The curriculum covers six topics:

n Psychobiology of the specific
mental illness;

n Diagnosis;

n Treatment and rehabilitation;

n Impact of mental illness on the family;

n Relapse prevention; and

n Family guidelines.

Rationale: Effectively teaching families new
information and skills requires structure
and systematically using specific evidence-
based techniques and strategies. Therefore,
it is critical that an FPE program has a
standardized educational curriculum that
specifies what is taught and how it is taught.

Sources of information: Curriculum review, schedule
of completed session, and interviews with
family intervention coordinator, FPE
practitioners, and families.

Item response coding: If 80 percent or more of involved
families receive a standardized educational curriculum
covering all six topics, code the item as “5.”

Probe questions

For family intervention coordinators:

n “Does your program have a standardized
educational curriculum?” [If yes, “May I have
a copy for review? How was it developed?”]

n “How do you ensure that the curriculum is
followed? Do you periodically evaluate and
update the curriculum? Do you have a schedule
of completed sessions and their content?”

n Ask about each area listed above and whether
they are included.

For FPE practitioners:

n “Do you use a standardized educational
curriculum?” [If yes, “Are there any areas you
teach differently from the curriculum?”]

n “Do you have a schedule of completed sessions
and their content?”

n Ask about each area listed above and whether
they are included.

For family members:

n Have you attended a 1-day educational
workshop? [If yes, “What topics were covered?”]

n Ask about each area listed above.

n “Did the FPE practitioners review these
educational topic areas with you individually or
in a group session?”

Evaluating Your Program 45 Appendix D: Fidelity Scale Protocol

10. Multimedia Education

Definition: Consumers and family members are given
educational materials about mental illnesses
in several formats (for example, paper,
video, and Web sites).

Rationale: Consumers and families benefit from
receiving educational materials in a variety
of formats. Some people may be more likely
to watch a video or search a website than to
read the same information in a document.

Sources of information: Review of educational materials
and interviews with the family intervention
coordinator, FPE practitioners, and families.

Item response coding: If educational materials are
provided to families and consumers in all three
formats, code the item as “5.”

Probe questions

For family intervention coordinators and FPE

practitioners:

n Ask to see the materials.

n “Do you provide educational materials to
families and consumers? How many families
and consumers on your caseload or in your FPE
program have received educational materials?”

n “Can you give or show me examples or the
types of materials that you give to families
and consumers?”

For family members and consumers:

n What types of educational materials have
you received through the FPE program?”
[If they suggest only written materials have
been provided, “Have you ever been offered
or given videos, Web site addresses, or material
in other formats?”

11. Structured Group Sessions

Definition: FPE practitioners adhere to a structured
procedure that includes:

n Beginning socialization;

n Review the last session’s action plan;

n Go-round;

n Selection of a single problem;

n Structured problem-solving; and

n Ending with socialization.

Rationale: Families and consumers benefit from
structured sessions that follow a predictable
pattern. FPE practitioners should establish
a clear agenda, goals, and expectations for
each FPE session.

Sources of information: Observation of FPE multifamily
group sessions and interviews with family
intervention coordinator, FPE practitioners,
consumers, and families.

Item response coding: If FPE multifamily group sessions
include all six components listed above, code the item
as “5.”

Probe questions

For family intervention coordinators

and FPE practitioners:

n Can you describe the typical FPE multifamily
group session?”

For consumers and family members:

n “Can you describe what you do at the beginning
of each multifamily group session? In the
middle? At the end?”

n “Does the FPE practitioner seem to have
a structured approach to each session?”

n “Is it clear to you what will be accomplished
in each session?”

Appendix D: Fidelity Scale Protocol 46 Evaluating Your Program

12. Structured Problem-Solving

Definition: FPE practitioners use a standardized
approach to help consumers and families
with problem-solving, which includes:

n Define the problem;

n Generate solutions;

n Discuss the advantages and disadvantages
of each solution;

n Choose the best solutions;

n Form an action plan; and

n Review the action plan.

Rationale: Studies show that collaborative and
structured problem-solving techniques
involving setting realistic goals and priorities
and breaking goals into small behavioral
steps are effective in improving consumers’
functioning and families’ coping.

Sources of information: Observation of FPE multifamily
group sessions and interviews with family
intervention coordinator, FPE practitioners,
consumers, and families.

Item response coding: If all six components of structured
problem-solving were used, code the item as “5.”

Probe questions
For family intervention coordinators and FPE
practitioners:

n “Do you focus on problem-solving in multifamily
groups?” [If yes, “What strategies do you use?
Do you follow the same process during every
session?”]

n Listen for the list of six components given above.
If a component is omitted, probe for whether it
is included.

For the family members and consumers:

n In the multifamily groups, do you discuss how to
address problems that may arise?” [If yes, “What
sorts of activities do you do in the sessions to
work on problems you may be having? Do you
ever generate plans of action? Is it a step-by-step
procedure? Can you describe the steps?”]

Evaluating Your Program 47 Appendix D: Fidelity Scale Protocol

13. Stage-Wise Provision of Services

Definition: FPE services are provided in the following
order:

1. Engagement;

2. Three or more joining sessions;

3. Educational workshop; and

4. Multifamily group.

Rationale: FPE is most effective if all components of
the evidence-based model are followed in
order. Effective FPE programs ensure that
consumers and families are well informed
about the practice, establish a strong
working alliance, receive a standardized
educational curriculum, and develop clear
treatment goals before entering into the
multifamily group.

Sources of information: Chart review and interviews
with family intervention coordinator, FPE
practitioners, consumers, and families.

Item response coding: If sources corroborate that
engagement, joining sessions, and the educational
workshop are completed in a step-wise manner before
entering into the multifamily group, code the item
as “5.”

Probe questions
For family intervention coordinators and FPE
practitioners:

n “How do you engage consumers and families
who would benefit from FPE?”

n “Do you provide joining sessions for consumers
and families?” [If yes, “How many joining
sessions has each consumer and family on your
caseload had? What kind of topics do you cover
in your joining sessions?”]

n “Did you offer a 1-day educational workshop?
When was it offered? How many consumers
and families attended? Did all the attendees
complete three or more joining sessions before
participating in the workshop?”

n “When did the multifamily group begin? Did
all group participants complete three or more
joining sessions and participate in the workshop
before the group began?”

For consumers and family members:

n Ask if he or she has received each of the four
services. Probe further about the timeframe
and content of each service.

n “Did you feel that you had a good understanding
of FPE before the multifamily group began?”

Appendix D: Fidelity Scale Protocol 48 Evaluating Your Program

14. Assertive Engagement and Outreach

Definition: FPE practitioners assertively engage all
potential consumers and family members by
phone, by mail, or in person (in the agency
or in the community) on an ongoing basis.

Rationale: All consumers and families who may benefit
from FPE should be educated about the
practice so that they can make informed
decisions about participation. Effective FPE
programs are flexible in meeting the needs
of individual families and consumers and
use a variety of means for reaching out to
them. Assertive engagement and outreach
is also crucial in overcoming barriers to
participation such as stigma and
hopelessness.

Sources of information: Chart review and interviews
with family intervention coordinator, FPE
practitioners, consumers, and families.

Item response coding: If FPE practitioners actively
engage all potential consumers and family members
through all necessary means on an ongoing basis, code
the item as “5.”

Probe questions
For family intervention coordinators and FPE
practitioners:

n “How do you engage consumers and families
who would benefit from FPE?”

n “How do you engage hard-to-reach consumers
and family members? For example, some
consumers may not have a phone number to
contact. Or, you may not be able to reach some
family members during your office hours
because they work.”

n “What would you do if a consumer or a family
member told you he or she was not ready
for FPE?”

n “What do you do with families who don’t show
up for treatment? What about families who
drop out of treatment? How do you engage
or re-engage these families?”

For consumers and family members:

n “How did you come to participate in this FPE
program? Did the program do a good job in
helping you understand FPE, explore your
expectations about the program, and make
an informed decision about participating?”

n “Have you ever felt discouraged or ambivalent
about participating in FPE or stopped showing
up for sessions?” [If yes, “What did the FPE
practitioner do to re-engage you in FPE?”]

n “How do you feel about the availability of
your FPE practitioner? Do you feel that your
practitioner actively reaches out to you?”
[If yes, “How does he or she do so?”]

Evaluating Your Program 49 Appendix E:

General Organizational Index

Evaluating Your Program

Appendix E: General Organizational Index
and Score Sheet

Evaluating Your Program 51 Appendix E: General Organizational Index

General Organizational Index
1 2 3 4 5

G1. Program philosophy

Committed to clearly articulated
philosophy consistent with specific
evidence-based practice (EBP) model,
based on these five sources:

n Program leader

n Senior staff (for example, executive
director, psychiatrist)

n Practitioners providing the EBP

n Consumers and families receiving EBP

n Written materials (for example,
brochures)

No more than
1 of 5 sources
shows clear
understanding
of program
philosophy.

OR

All sources
have numerous
major areas of
discrepancy.

2 of 5 sources
show clear
understanding
of program
philosophy.

OR

All sources
have several
major areas of
discrepancy.

3 of 5 sources
show clear
understanding
of program
philosophy.

OR

Sources mostly
aligned to
program
philosophy, but
have 1 major area
of discrepancy.

4 of 5 sources
show clear
understanding
of program
philosophy.

OR

Sources mostly
aligned to
program
philosophy,
but have 1 or 2
minor areas of
discrepancy.

All 5 sources
show clear
understanding
and commitment
to program
philosophy for
specific EBP.

*G2. Eligibility or consumer

identification

All consumers with serious mental
illnesses in the community support
program, crisis consumers, and
institutionalized consumers are screened
to determine if they qualify for EBP
using standardized tools or admission
criteria consistent with EBP. Also, agency
systematically tracks number of eligible
consumers.

20% of
consumers receive
standardized
screening and/
or agency
DOES NOT
systematically
track eligibility.

21–40% of
consumers receive
standardized
screening
and agency
systematically
tracks eligibility.

41–60% of
consumers receive
standardized
screening
and agency
systematically
tracks eligibility.

61–80% of
consumers receive
standardized
screening
and agency
systematically
tracks eligibility.

>80% of
consumers receive
standardized
screening
and agency
systematically
tracks eligibility.

*

G3. Penetration

Maximum number of eligible consumers
served by EBP, as defined by the ratio:

Number of consumers receiving EBP
Number of consumers eligible for EBP

Ratio .20 Ratio .21 – .40 Ratio .41 – .60 Ratio .61 – .80 Ratio > .80

* These two items coded based on all consumers with serious mental illnesses at the site or sites where EBP is being implemented; all other
items refer specifically to those receiving the EBP.

Total number of consumers in target population

Total number of consumers eligible for EBP % % eligible:

Total number of consumers receiving EBP Penetration rate

Appendix E: General Organizational Index 52 Evaluating Your Program

1 2 3 4 5

G4. Assessment Assessments are
completely absent
or completely
non-standardized.

Pervasive
deficiencies in 2
of the following:

n Standar di zation;

n Quality of
assessments;

n Timeliness; and

n Comprehen-
siveness.

Pervasive
deficiencies in 1
of the following:

n Standar di zation;
n Quality of
assessments;
n Timeliness; and
n Comprehen-
siveness.

61%-80% of
consumers receive
standardized,
high-quality
assessments at
least annually.

OR

Information is
deficient for 1
or 2 assessment
domains.

More than 80%
of consumers
receive
standardized,
high-quality
assessments, the
information is
comprehensive
across all
assessment
domains, and it
is updated at least
annually.

Full standardized assessment of all
consumers who receive EBP services.
Assessment includes the following:

n History and treatment of medical,
psychiatric, substance use disorders

n Current stages of all existing disorders

n Vocational history

n Any existing support network

n Evaluation of biopsychosocial
risk factors

G5. Individualized treatment plan 20% of
consumers
EBP serves
have explicit
individualized
treatment plan,
related to EBP,
updated every
3 months.

21–40%
of consumers
EBP serves
have explicit
individualized
treatment plan,
related to EBP,
updated every
3 months.

41–60% of
consumers
EBP serves
have explicit
individualized
treatment plan,
related to EBP,
updated every
3 months.

OR

Individualized
treatment plan
updated every
6 months for all
consumers.

61–80% of
consumers
EBP serves
have explicit
individualized
treatment plan,
related to EBP,
updated every
3 months.

More than 80%
of consumers
EBP serves
have explicit
individualized
treatment plan
related to EBP,
updated every
3 months.

For all EBP consumers, an explicit,
individualized treatment plan exists
related to the EBP that is consistent with
assessment and updated every 3 months

G6. Individualized treatment 20% of
consumers EBP
serves receive
individualized
services meeting
goals of EBP.

21–40% of
consumers EBP
serves receive
individualized
services meeting
goals of EBP.

41–60% of
consumers EBP
serves receive
individualized
services meeting
goals of EBP.

61–80% of
consumers EBP
serves receive
individualized
services meeting
goals of EBP.

More than 80%
of consumers EBP
serves receive
individualized
services meeting
goals of EBP.

All EBP consumers receive individualized
treatment meeting goals of EBP

G7. Training 20% of program
staff receive
standardized
training annually.

21–40%
of program
staff receive
standardized
training annually.

41–60%
of program
staff receive
standardized
training annually.

61–80%
of program
staff receive
standardized
training annually.

More than 80%
of program
staff receive
standardized
training annually.

All new program staff receive
standardized training in EBP (at least
a 2-day workshop or equivalent) within
2 months after hiring. Existing program
staff receive annual refresher training
(at least 1-day workshop or equivalent).

G8. Supervision 20% of EBP
practitioners
receive
supervision.

21–40% of EBP
practitioners
receive weekly
structured,
consumer-
centered
supervision.

OR

All EBP
practitioners
receive informal
supervision.

41–60% of EBP
practitioners
receive weekly
structured,
consumer-
centered
supervision.

OR

All EBP
practitioners
receive monthly
supervision.

61–80% of EBP
practitioners
receive weekly
structured,
consumer-
centered
supervision.

OR

All EBP
practitioners
receive
supervision 2
times a month.

More than
80% of EBP
practitioners
receive
structured weekly
supervision,
focusing
on specific
consumers,
in sessions that
explicitly address
EBP model and
its application.

EBP practitioners receive structured,
weekly supervision (group or individual
format) from a supervisor experienced
in particular EBP. Supervision should
be consumer-centered and explicitly
address EBP model and its application
to specific consumer situations.

Evaluating Your Program 53 Appendix E: General Organizational Index

1 2 3 4 5

G9. Process monitoring No attempt
at process
monitoring
is made.

Informal process
monitoring is
used at least
annually.

Process monitor-
ing is deficient
on 2 of these 3
criteria:

n Comprehen-
sive and

standardized;

n Completed
every 6
months; and

n Used to guide
program
improvements.

OR

Standardized
monitoring done
annually only.

Process
monitoring is
deficient on 1 of
these 3 criteria:

n Comprehen-
sive and
standardized;
n Completed
every 6
months; and
n Used to guide
program
improvements.

Standardized
comprehensive
process
monitoring
occurs at least
every 6 months
and is used to
guide program
improvements.

Program leaders and administrators
monitor process of implementing EBP
every 6 months and use the data to
improve the program. Monitoring
involves a standardized approach, for
example, using fidelity scale or other
comprehensive set of process indicators.

G10. Outcome monitoring No outcome
monitoring
occurs.

Outcome
monitoring
occurs at least 1
time a year, but
results are not
shared with EBP
practitioners.

Standardized
outcome moni-
toring occurs at
least 1 time a
year. Results are
shared with EBP
practitioners.

Standardized
outcome
monitoring occurs
at least 2 times a
year. Results are
shared with EBP
practitioners.

Standardized
outcome
monitoring
occurs quarterly.
Results are
shared with EBP
practitioners.

Program leaders and administrators
monitor outcomes for EBP consumers
every 3 months and share data with
EBP practitioners. Monitoring involves
standardized approach to assessing a key
outcome related to EBP, for example,
psychiatric admissions, substance abuse
treatment scale, or employment rate.

G11. Quality Assurance (QA) No review or
no committee.

QA committee has
been formed, but
no reviews have
been completed.

Explicit QA review
occurs less than
annually.

OR

QA review
is superficial.

Explicit QA review
occurs annually

Explicit review
occurs every 6
months by QA
group or steering
committee for
EBP

Agency has QA committee or
implementation steering committee
with an explicit plan to review EBP
or components of the program every
6 months.

G12. Consumer choice about
service provision

Consumer-
centered services
are absent
(or practitioners
make all EBP
decisions).

Few sources agree
that type and
frequency of EBP
services reflect
consumer choice

Half of the
sources agree
that type and
frequency of EBP
services reflect
consumer choice.

Most sources
agree that type
and frequency
of EBP services
reflect consumer
choice.

OR

Agency fully
embraces
consumer choice
with 1 exception.

All sources agree
that type and
frequency of EBP
services reflect
consumer choice.

All consumers receiving EBP services
are offered choices; EBP practitioners
consider and abide by consumer
preferences for treatment when offering
and providing services. Score Sheet:
General Organizational Index

Appendix E: General Organizational Index 54 Evaluating Your Program

Score Sheet: General Organizational Index

Date of visit
Agency name

Assessors’ names

Assessor 1 Assessor 2 Consensus

G1 Program philosophy

G2 Eligibility or consumer identification

G3 Penetration

G4 Assessment

G5 Individualized treatment plan

G6 Individualized treatment

G7 Training

G8 Supervision

G9 Process monitoring

G10 Outcome monitoring

G11 Quality Assurance (QA)

G12 Consumer choice regarding service provision

Total mean score

/ /

Evaluating Your Program 55 Appendix F: GOI Protocol

Evaluating Your Program

Appendix F: General Organizational Index Protocol

Evaluating Your Program 57 Appendix F: GOI Protocol

General Organizational
Index Protocol

The General Organizational Index Protocol
explains how to rate each item of the index.
In particular, it provides the following:

n A definition and rationale for each item; and

n A list of data sources most appropriate for each
fidelity item (for example, chart review, program
leader, practitioners, consumers, and family
interviews).

When appropriate, a set of probe questions is
provided to help you elicit the critical information
needed to code the fidelity item. These probe
questions were specifically generated to help you
collect information from respondents that is
relatively free from bias, such as social desirability.

Decision rules will help you code each item
correctly. As you collect information from various
sources, these rules will help you determine the
specific rating to give for each item.

G1. Program Philosophy

Definition: The program is committed to a clearly
articulated philosophy consistent with the
specific evidence-based practice (EBP),
based on the following five sources:

n Family intervention coordinator;

n Senior staff (for example, executive
director, psychiatrists);

n FPE practitioners;

n Consumers and family members; and

n Written materials (for example,
brochures).

Rationale: In agencies that truly endorse EBPs, staff
members at all levels embrace the program
philosophy and practice it in their daily work.

Sources of information:

Overview: During the site visit, be alert to indicators of
program philosophy consistent or inconsistent with the
EBP, including observations from casual conversations,
staff and consumer activities, etc. Statements that
suggest misconceptions or reservations about the
practice are negative indicators, while statements that
show enthusiasm for and understanding of the practice
are positive indicators.

The intent of this item is to gauge the understanding of
and commitment toward the practice. It is not
necessary that every element of the practice is
currently in place (this is gauged by the EBP-specific
fidelity scale), but rather whether all those involved are
committed to implementing a high-fidelity EBP.

The practitioners rated for this item are limited
to those implementing this practice. Similarly, the
consumers rated are those receiving the practice.

1. Family intervention coordinator, senior staff,

and

practitioner interviews

At the beginning of the interview, have
practitioners briefly describe the program.

n “What are the critical ingredients or principles of
your services?”

n “What is the goal of your program?”

n “How do you define [EBP area]?”

2. Consumer interview

n “What kind of services do you receive from this
program?”

n Using a layperson’s language, describe to the
consumer or family the principles of the specific
EBP area. [Probe if the program offers services
that reflect each principle.]

n “Do you feel the practitioners of this program
are competent and help you address your
problems?”

3. Written material review (for example, brochure)

n Does the site have written materials on the
EBP? If not, then rate item down one scale point
(i.e., lower fidelity).

n Does the written material articulate a program
philosophy that is consistent with the EBP?

Appendix F: GOI Protocol 58 Evaluating Your Program

Item response coding: The goal of this item is not to quiz
every practitioner to determine if each can recite every
critical ingredient. Rather, the goal is to gauge whether
the understanding is generally accurate and not contrary
to the EBP. For example, if a senior staff member says,
“We are having trouble identifying consumers for our
FPE program since most families are unsupportive,”
then that would be a red flag for the practice of FPE.

If all sources show evidence that they clearly understand
the program philosophy, code the item as “5.” For a
source type that is based on more than one person (for
example, practitioner interviews) determine the majority
opinion when rating whether that source endorses a
clear program philosophy. Note: If no written material
exists, then count that source as unsatisfactory.

G2. Eligibility/Consumer Identification

Definition: For EBPs implemented in a mental health
center: All consumers in the community
support program, consumers in crisis, and
those in the hospital are screened using
standardized tools or admission criteria that
are consistent with the EBP.

For EBPs implemented in a service area:
All consumers within the jurisdiction of the
service area are screened using standardized
tools or admission criteria that are consistent
with the EBP. For example, in New York,
county mental health administrations are
responsible for identifying consumers who
will be served by Assertive Community
Treatment (ACT) programs.

The target population refers to all adults
with serious mental illness (SMI) served by
the provider agency or service area. If the
agency serves consumers at multiple sites,
then assessment is limited to the site or sites
that are targeted for the EBP. If the target
population is served in discrete programs
(for example, case management, residential,
day treatment), then ordinarily all adults
with serious mental illnesses are included
in this definition.

Screening will vary according to the EBP.
The intent is to identify all who could
benefit from the EBP. In every case, the
program should have an explicit, systematic
method for identifying the eligibility of
every consumer. Screening typically occurs
at program admission; programs that are
newly adopting an EBP should have a plan
for systematically reviewing consumers who
are already active in the agency.

Rationale: Accurately identifying consumers who
would benefit most from the EBP requires
routinely reviewing eligibility, based on
criteria that are consistent with the EBP.

Sources of information:

1. Family intervention coordinator, senior staff,

and practitioner interviews

n “Describe the eligibility criteria for your
program.”

n “How are consumers referred to your program?
How does the agency identify consumers who
would benefit from your program? Do all new
consumers receive screening for substance abuse
or severe mental illness (SMI) diagnosis?”

n “What about consumers who are in crisis
(or institutionalized)?”

n Ask for a copy of the screening instrument that
the agency uses.

2. Chart review

Review documentation of the screening process
and results.

3. County mental health administrators (where applicable)

If eligibility is determined at the service-area level
(such as the New York example), then interview the
people who are responsible for this screening.

Item response coding: This item refers to all consumers
with SMI in the community support program or its
equivalent at the sites where the EBP is being
implemented; it is not limited to consumers who
receive EBP services only. Calculate this percentage
and record it on the fidelity scale in the space
provided. If 80 percent or more of these consumers
receive standardized screening, code the item as “5.”

Evaluating Your Program 59 Appendix F: GOI Protocol

G3. Penetration

Definition: Penetration is defined as the percentage
of consumers who have access to an EBP
as measured against the total number of
consumers who could benefit from the EBP.
Numerically, this proportion is defined by––

Number of consumers receiving an EBP

Number of consumers eligible for the EBP

As in the preceding item, the numbers used
in this calculation are specific to the site or
sites where the EBP is being implemented.

Rationale: Surveys have repeatedly shown that people
with SMI often have a limited access to
EBPs. The goal of EBP dissemination is not
simply to create small exclusive programs,
but to make these practices easily accessible
within the public mental health system.

Sources of information:

The calculation of the penetration rate depends on the
availability of the two statistics defining this rate.

Numerator: The number receiving the service is based
on a roster of names that the family intervention
coordinator maintains. Ideally, this total should be
corroborated with service contact sheets and other
supporting evidence that the identified consumers are

actively receiving treatment. As a practical matter,
agencies have many conventions for defining active
consumers and dropouts, so that it may be difficult to
standardize the definition for this item. Use the best
estimate of the number actively receiving treatment.

Denominator: If the agency systematically tracks
eligibility, then use this number in the denominator.
(See the rules listed in G2 to determine the target
population before using estimates below.) If the agency
doesn’t track eligibility, then estimate the denominator
by multiplying the total target population by the
corresponding percentage based on the literature for
each EBP.

According to the literature, the estimates for EBP
KITs available at this writing should be as follows:

n Integrated Treatment for Co-Occurring

Disorders––40 percent

n Supported Employment––60 percent

n Illness Management and Recovery––100 percent

n Family Psychoeducation––100 percent (some
kind of significant other)

n Assertive Community Treatment––20 percent

Item response coding: Calculate this ratio and record it
on the fidelity scale. If the program serves more than
80 percent of eligible consumers, code the item as “5.”

Appendix F: GOI Protocol 60 Evaluating Your Program

G4. Assessment

Definition: All EBP consumers receive standardized,
high-quality, comprehensive, and timely
assessments.

Standardization refers to a reporting format
that is easily interpreted and consistent
across consumers.

High quality refers to assessments that
provide concrete, specific information that
differentiates among consumers. If most
consumers are assessed using identical
words or if the assessment consists of broad,
noninformative checklists, then consider
this to be low quality.

Comprehensive assessments include the
following:

n History and treatment of medical,
psychiatric, and substance use disorders;

n Current stages of all existing disorders;

n Vocational history;

n Any existing support network; and

n Evaluation of biopsychosocial risk factors.

Timely assessments are those updated
at least annually.

Rationale: Comprehensive assessment or re-
assessment is indispensable in identifying
target domains of functioning that may need
intervention, in addition to consumers’
progress toward recovery.

Sources of information:

1. Family intervention coordinator, senior staff, and

practitioner interviews

n “Do you give a comprehensive assessment
to new consumers? What are the components
thatxyou assess?”

n Ask for a copy of the standardized assessment
form, if available, and have practitioners go
through the form.

n “How often do you re-assess consumers?”

2. Chart review

n Look for comprehensiveness of assessment
by looking at multiple completed assessments
to see if they address each component of the
comprehensive assessment every time an
assessment is performed.

n “Is the assessment updated at least yearly?”

Item response coding: If more than 80 percent
of consumers receive standardized, high-quality,
comprehensive, and timely assessments, code the
item as “5.”

Evaluating Your Program 61 Appendix F: GOI Protocol

G5. Individualized Treatment Plan

Definition: For all EBP consumers, an explicit,
individualized treatment plan exists (even if
it is not called this) related to the EBP that
is consistent with assessment and updated
every 3 months.

Individualized means that goals, steps
to reaching the goals, services and
interventions, and intensity of involvement
are unique to this consumer. Plans that
are the same or similar across consumers
are not individualized. One test is to place
a treatment plan without identifying
information in front of supervisors to
see if they can identify the consumer.

Rationale: Core values of EBP include individualizing
services and supporting consumers’ pursuit
of their goals and progress in their recovery
at their own pace. Therefore, treatment
plans need ongoing evaluation
and modification.

Sources of information:

Note: Assess this item and the next together; that is,
ask questions about specific treatment plans along
with questions about the treatment.

1. Chart review (treatment plan)

Using the same charts as examined during
the EBP-specific fidelity assessment, look for
documentation of specific goals and consumer-
based, goal-setting process.

n “Are the treatment recommendations consistent
with assessment?”

n “What evidence is used for a quarterly review?”

2. Family intervention coordinator interview

“Describe the process of developing a treatment
plan. What are the critical components of a typical
treatment plan and how are they documented?”

3. Practitioner interview

When feasible, use the specific charts selected
above. Ask practitioners to go over a sample
treatment plan.

n “How do you come up with consumer goals?”
[Listen for consumer involvement and
individualization of goals.]

n “How often do you review (or follow up on)
the treatment plan?”

4. Consumer interview

n “What are your goals in this program? How did
you set these goals?”

n “Do you and your practitioners together review
your progress toward achieving your goals?”
[If yes, “How often? Please describe the
review process.”]

5. Team meeting and supervision observation,

if available

Observe how the treatment plan is developed.
Listen especially for discussion of assessment,
consumer preferences, and individualization
of treatment. Do they review treatment plans?

Item response coding: If more than 80 percent of EBP
consumers have an explicit, individualized treatment
plan that is updated every 3 months, code the item
as “5.”

If the treatment plan is individualized but updated
only every 6 months, code the item as “3.”

Appendix F: GOI Protocol 62 Evaluating Your Program

G6. Individualized Treatment

Definition: All EBP consumers receive individualized
treatment meeting the goals of the EBP.

Individualized treatment means that steps,
strategies, services, interventions, and
intensity of involvement are focused on
specific consumer goals and are unique
for each consumer. Progress Notes are
often a good source of what really goes on.
Treatment could be highly individualized,
despite the presence of generic
treatment plans.

An example of a low score on this item
for Integrated Treatment of Co-Occurring
Disorders is the following:

If consumers in the engagement phase of recovery
are assigned to a relapse prevention group and are
constantly told they need to quit using, rather than
using motivational interventions.

Rationale: The key to the success of an EBP is
implementing a plan that is individualized
and meets the goals for the EBP for
each consumer.

Sources of information:

1. Chart review (treatment plan)

Using the same charts as examined during the
EBP-specific fidelity assessment, examine the
treatment provided. Limit the focus to a recent
treatment plan related to the EBP. Judge whether
an appropriate treatment occurred during the time
frame indicated by the treatment plan.

2. Practitioner interview

When feasible, use the specific charts selected
above. Ask practitioners to go over a sample
treatment plan and treatment.

3. Consumer interview

“Tell me about how this program is helping
you meet your goals.”

Item response coding: If more than 80 percent of EBP
consumers receive treatment that is consistent with
the goals of the EBP, code the item as “5.”

G7. Training

Definition: All new practitioners receive standardized
training in the EBP (at least a 2-day
workshop or its equivalent) within 2 months
after they are hired. Existing practitioners
receive annual refresher training (at least
a 1-day workshop or its equivalent).

Rationale: Practitioner training and retraining are
warranted to ensure that evidence-based
services are provided in a standardized
manner, across practitioners and over time.

Sources of information:
1. Family intervention coordinator, senior staff,
and practitioner interviews

n “Do you provide new practitioners with
systematic training for [EBP area]?” [If yes,
probe for specifics: Mandatory or optional?
Length? Frequency? Content? Group or
individual format? Who trains? In-house
or outside training?]

n “Do practitioners receive refresher trainings?”
[If yes, probe for specifics.]

2. Review training curriculum and schedule, if available

Does the curriculum appropriately cover
the critical ingredients for [EBP area]?

3. Practitioners interview

n “When you first started in this program, did
you receive a systematic and formal training
for [EBP area]?” [If yes, probe for specifics:
Mandatory or optional? Length? Frequency?
Content? Group or individual format?
Who trains? In-house or outside training?]

n “Do you receive refresher trainings?” [If yes,
probe for specifics.]

Item response coding: If more than 80 percent of
practitioners receive at least yearly, standardized
training for [EBP area], code the item as “5.”

Evaluating Your Program 63 Appendix F: GOI Protocol

G8. Supervision

Definition: FPE practitioners receive structured,
weekly supervision from a supervisor
experienced in the particular EBP.
The supervision can be either group or
individual, but CANNOT be peers-only
supervision without a supervisor. The
supervision should be consumer-centered
and explicitly address the EBP model and
how it applies to specific consumer
situations. Administrative meetings and
meetings that are not specifically devoted to
the EBP do not fit the criteria for this item.
The consumer-specific EBP supervision
should be at least 1 hour each week.

Rationale: Regular supervision is critical not only
for individualizing treatment, but also
for ensuring the standardized provision
of evidence-based services.

Sources of information:
1. Family intervention coordinator, senior staff,
and practitioner interviews

Probe for logistics of supervision: length, frequency,
group size, etc.

n “Describe what a typical supervision session
looks like.”

n “How does the supervision help your work?”

2. Team meeting and supervision observation, if available

Listen for discussion of [EBP area] in each
case reviewed.

3. Supervision logs documenting frequency of meetings

Item response coding: If more than 80 percent of FPE
practitioners receive weekly supervision, code the item
as “5.”

G9. Process Monitoring

Definition: Family intervention coordinators and
administrators monitor the process of
implementing the EBP every 6 months and
use the data to improve the program. Process
monitoring involves a standardized approach,
for example, using a fidelity scale or other
comprehensive set of process indicators.

An example of a process indicator would
be a systematic measurement of how much
time case managers spend in the community
instead of in the office. Process indicators
could include items related to training or
supervision. The underlying principle is that
whatever is being measured is related to
implementing the EBP and is not being
measured to track billing or productivity.

Rationale: Systematically and regularly collecting
process data is imperative in evaluating
program fidelity to EBP.

Sources of information:
1. Family intervention coordinator, senior staff,

and practitioners interviews

n “Does your program collect process data
regularly?” [If yes, probe for specifics.
Frequency? Who? How (using [EBP area]
fidelity scale vs. other scales)? etc.]

n “Does your program collect data on consumer
service use and treatment attendance?”

n “Have the process data affected how your
services are provided?

2. Review of internal reports and documentation,

if available

Item response coding: If evidence exists that
standardized process monitoring occurs at least
every 6 months, code the item as “5.”

Appendix F: GOI Protocol 64 Evaluating Your Program

G10. Outcome Monitoring

Definition: Family intervention coordinators and
administrators monitor the outcomes of
EBP consumers every 3 months and share
the data with FPE practitioners in an effort
to improve services. Outcome monitoring
involves a standardized approach to
assessing consumers.

Rationale: Systematically and regularly collecting
outcomes data is imperative in evaluating
program effectiveness. Effective programs
also analyze such data to ascertain what is
working and what is not working and use
the results to improve the quality of services
they provide.

Key outcome indicators for each EBP are
discussed in the EBP KITs. A provisional
list is as follows:

n Integrated Treatment for Co-Occurring

Disorders—substance use (such as
the Stages of Treatment Scale);

n Supported Employment—competitive
employment rate;

n Illness Management and Recovery—
hospitalization rates, relapse prevention
plans, medication compliance rates;

n Family Psychoeducation—hospitalization
and family well-being; and

n Assertive Community Treatment—
hospitalization and housing.

Sources of information:
1. Family intervention coordinator, senior staff,
and practitioner interviews

n “Does your program have a systematic method
for tracking outcomes data?” [If yes, probe for
specifics: How (computerized vs. chart only)?
How often? Type of outcome variables?
Who collects data?]

n “Do you use any checklist or scale to monitor
consumer outcome (for example, Substance
Abuse Treatment Scale)?”

n “What do you do with the outcomes data?
Do your practitioners review the data regularly?”
[If yes, “How is the review done (for example,
cumulative graph)?”]

n “Have the outcomes data affected how your
services are provided?” [If yes, “How?”]

2. Review of internal reports and documentation,
if available

Item response coding: If standardized outcome
monitoring occurs quarterly and results are shared
with FPE practitioners, code the item as “5.”

Evaluating Your Program 65 Appendix F: GOI Protocol

G11. Quality Assurance

Definition: The agency’s quality assurance (QA)
committee has an explicit plan to review the
EBP or components of the program every 6
months. The steering committee for the
EBP can serve this function.

Good QA committees help the agency in
important decisions, such as penetration
goals, placement of the EBP within the
agency, and hiring and staffing needs. QA
committees also help guide and sustain the
implementation by doing the following:

n Reviewing fidelity to the EBP model;

n Making recommendations for
improvement;

n Advocating and promoting the EBP
within the agency and in the community;
and

n Deciding on and keeping track of key
outcomes relevant to the EBP.

Rationale: Research has shown that programs that
most successfully implement EBPs have
better outcomes. Again, systematically and
regularly collecting process and outcomes
data is imperative in evaluating program
effectiveness.

Sources of information:

1. Family intervention coordinator interview

“Does your agency have an established team or
committee that is in charge of reviewing the
components of your [EBP area] program?” [If yes,
probe for specifics. “Who? How? When?”]

2. QA committee member interview

n “Please describe the tasks and responsibilities
of the QA committee.” [Probe for specifics.
“What is the purpose? Who? How? When?”]

n “How do you use your reviews to improve the
program’s services?”

Item response coding: If the agency has an established
QA or steering committee that reviews the EBP or
components of the program every 6 months, code the
item as “5.”

Appendix F: GOI Protocol 66 Evaluating Your Program

G12. Consumer Choice About Service
Provision

Definition: All consumers who receive EBP services are
offered a reasonable range of choices
consistent with the EBP; practitioners
consider and abide by consumer
preferences for treatment when they offer
and provide services.

Choice is defined narrowly in this item to
refer to services provided. This item does
not address broader issues of consumer
choice such as choosing to engage in self-
destructive behaviors.

To score high on this item, it is not sufficient
that a program offers choices. The choices
must be consonant with the EBP. So, for
example, an agency implementing
Integrated Treatment for Co-Occurring
Disorders would score low if it only worked
with consumers who were abstinent.

A reasonable range of choices means that
FPE practitioners offer realistic options to
consumers rather than prescribing only one
or a couple of choices or dictating a fixed
sequence or prescribing conditions that
consumers must complete before becoming
eligible for a service.

Examples of Relevant Choices
by EBPs

Current at this writing

Integrated Treatment for Co-Occurring
Disorders

n Group or individual counseling sessions

n Frequency of treatment

n Specific self-management goals

n Selection of other supporters to be involved

Supported Employment

n Type of occupation

n Type of work setting

n Schedules of work and number of hours

n Whether to disclose

n Nature of accommodations

n Type and frequency of followup supports

Family Psychoeducation

n Consumer readiness for involving family

n Who to involve

n Choice of problems and issues to work on

Illness Management and Recovery

n Selection of other supporters to be involved
n Specific self-management goals

n Nature of behavioral tailoring

n Skills to be taught

Assertive Community Treatment

n Type and location of housing

n Nature of health promotion

n Nature of assistance with financial
management

n Specific goals

n Daily living skills to be taught

n Nature of medication support

n Nature of substance abuse treatment

Evaluating Your Program 67 Appendix F: GOI Protocol

Rationale: A major premise of EBP is that consumers
are capable of playing a vital role in
managing their illnesses and in making
progress towards achieving their goals.
Providers accept the responsibility for getting
information to consumers so that they can
more effectively participate in treatment.

Sources of information:
1. Family intervention coordinator interview

n “Tell us what your program philosophy
is about consumer choice. How do you
incorporate consumers’ preferences in
the services you provide?”

n “What options exist for your services?
Give examples.”

2. Practitioner interview

n “What do you do when a disagreement occurs
between what you think is the best treatment
for consumers and what they want?”

n “Describe a time when you were unable to abide
by a consumer’s preferences.”

3. Consumer interview:

n “Does the program give you options
for the services you receive?”

n Are you receiving the services you want?”

4. Team meeting and supervision observation

Look for discussion of service options
and consumer preferences.

5. Chart review (especially treatment plan)

Look for documentation of consumer preferences
and choices.

Item response coding: If all sources support that type
and frequency of EBP services always reflect consumer
choice, code the item as “5.”

If the agency embraces consumer choice fully except
in one area (for example, requiring the agency to
assume representative payeeships for all consumers),
then code the item as “4.”

Note: Ratings for both scales are based on current
behavior and activities, not planned or intended
behavior.

The standards used for establishing the anchors for the
fully implemented ratings were determined through a
variety of expert sources as well as empirical research.

Evaluating Your Program 69 Appendix G:

Outcomes Report Form

Evaluating Your Program

Appendix G: Outcomes Report Form

Evaluating Your Program 71 Appendix G: Outcomes Report Form

Outcomes Report Form

Quarter q January, February, March Year
q April, May, June
q July, August, September
q October, November, December
Reported by
Agency Team

About the consumer

Consumer ID Discharge date Date of birth

q Male Ethnicity
q Female Primary diagnosis

What was the consumer’s evidence-based service status on the last day of the quarter?

Unknown Not Eligible Eligible Enrolled

Integrated Treatment for Co-Occurring Disorders q q q q

Supported Employment q q q q

Assertive Community Treatment q q q q

Illness Management and Recovery q q q q

Family Psychoeducation q q q q

In the past 3 months, how often has the consumer… Number of days
Number of
incidents

Been homeless?

Been incarcerated?

Been in a State psychiatric hospital?

Been in a private psychiatric hospital?

Been hospitalized for substance abuse reasons?

/ / / /

Appendix G: Outcomes Report Form 72 Evaluating Your Program

In the past 3 months, how many days was the consumer

competitively employed? (Use 0 if the consumer has not been
competitively employed.)

_____________ Days

Was the consumer competitively employed on the last day

of the reporting period?

q

Yes

q No

What was the consumer’s stage of substance abuse treatment

on the last day

of the quarter? Check one.

q Not applicable

q Pre-engagement

q Engagement

q Early persuasion

q Late persuasion

q Early active treatment

q Late active treatment

q Relapse prevention

q In remission or recovery

What was the consumer’s living arrangement on the last day

of the quarter? Check one.

q Not applicable or unknown

q Psychiatric hospital

q Substance abuse hospitalization

q General hospital psychiatric ward

q Nursing home

q Family care home

q Living with relatives (heavily dependent for personal care)

q Group home

q Boarding house

q Supervised apartment program

q Living with relatives (but is largely independent)

q Living independently

q Homeless

q Emergency shelter

q Other (specify): ____________________________

What was the consumer’s educational status on the last day

of the quarter? Check one.

q Not applicable or unknown

q No educational participation

q Avocational/Educational involvement

q Pre-educational explorations

q Working on General Educational Development (GED) diploma

q Working on English as Second Language

q Basic educational skills

q Attending vocational school, vocational program,
apprenticeship, or high school

q Attending college: 1 to 6 hours

q Attending college: 7 or more hours

q Other (specify): ____________________________

What is the consumer’s highest level of education? Check one.

q No high school

q High school diploma or General Educational Development
(GED) diploma

q Some college

q Associate degree

q Vocational training certificate

q Bachelor of Arts or Bachelor of Science

q Master’s degree or Ph.D.

Evaluating Your Program 73 Appendix H:

Instructions for the Outcomes Report Form

Evaluating Your Program

Appendix H: Instructions for the Outcomes Report Form

Evaluating Your Program 75 Appendix H: Instructions for the Outcomes Report Form

Instructions for the Outcomes Report Form

Before you fill out the Outcomes Report Form, become familiar with the definitions of the data elements to
provide consistency among reporters.

Evidence-based service status

What was the consumer’s evidence-based service

status on the last day of the quarter? Check the
appropriate boxes according to these definitions:

Eligible: Does the consumer meet the participation
criteria for a specific EBP? Each EBP has
criteria for program participation that
should be used to determine eligibility.

Enrolled: Is the consumer participating in a particular
EBP service or has the consumer
participated in the EBP in the past period?
Note: Aggregate data about eligibility and
enrollment can be used to determine the
percent of eligible consumers who
received services.

Incident reporting

For the following outcomes, record the number of
days and number of incidents that the consumer spent
in each category during the reporting period.

Categories:

n Been homeless: Number of days that the
consumer was homeless and how many times
the consumer was homeless during the reporting
period. Homeless refers to consumers who lack a
fixed, regular, and adequate nighttime residence.

n Been incarcerated: Number of days and incidents
that the consumer spent incarcerated in jails or
in other criminal justice lockups.

n Been in a state psychiatric hospital: Number of
days and incidents that the consumer spent
hospitalized primarily for treatment of psychiatric
disorders in a state psychiatric hospital.

General data

Quarter: Check the time frame for the reporting
period.

Year: Fill in the current year.

Reported by: Fill in the name and title of the person
who completed the form.

Agency: Identify the agency name.

Team: Write the team name or number.

About the consumer

Consumer ID: Write the consumer ID that is used
at your agency, usually a name or an
identifying number. This information will
be accessible only to the agency providing
the service.

Discharge date: If the consumer has been discharged
during this report period, fill in the
discharge date.

Date of birth: Fill in the consumer’s date of birth
(Example: 09/22/1950).

Gender: Check the appropriate box.

Ethnicity: Fill in the consumer’s ethnicity.

Primary diagnosis: Write the DSM diagnosis.

Appendix H: Instructions for the Outcomes Report Form 76 Evaluating Your Program

n Been in a private psychiatric hospital: Number
of days and incidents that the consumer spent
hospitalized primarily for treatment of
psychiatric disorders in a private
psychiatric hospital.

n Been hospitalized for substance abuse reasons:

Number of days and incidents that the consumer
spent hospitalized primarily for treatment of
substance use disorders, including both public
and private hospitals whose primary function
is treating substance use disorders.

Competitive employment

In the past 3 months, how many days was the consumer

competitively employed? Competitive employment
means working in a paid position (almost always
outside the mental health center) that would be open
to all community members to apply. Competitive
employment excludes consumers working in sheltered
workshops, transitional employment positions, or
volunteering. It may include consumers who are self-
employed but only if the consumer works regularly and
is paid for the work.

Stage of substance abuse treatment

What was the consumer’s stage of substance abuse

treatment on the last day of the quarter? Record the
consumer’s stage of substance abuse recovery,
according to the following nine categories:

n Not applicable: No history of substance abuse
disorder.

n Pre-engagement: No contacts with a case
manager, mental health counselor, or integrated
treatment specialist.

n Engagement: Contact with an assigned case
manager or counselor, but does not have regular
contacts. The lack of regular contact implies lack
of a working alliance.

n Early persuasion: Regular contacts with a case
manager or counselor, but has not reduced
substance use for more than a month. Regular
contacts imply having a working alliance and a
relationship in which substance abuse can be
discussed.

n Late persuasion: Engaged in a relationship with a
case manager or counselor, is discussing
substance use or attending a group, and shows
evidence of reducing use for at least 1 month
(fewer drugs, smaller quantities, or both).
External controls (for example, Antabuse) may
be involved in reduction.

n Early active treatment: Engaged in treatment, is
discussing substance use or attending a group,
has reduced use for at least 1 month, and is
working toward abstinence (or controlled use
without associated problems) as a goal, even
though consumer may still be abusing.

n Late active treatment: Engaged in treatment, has
acknowledged that substance abuse is a problem,
and has achieved abstinence (or controlled use
without associated problems) but for less than 6
months.

n Relapse prevention: Engaged in treatment, has
acknowledged that substance abuse is a problem,
and has achieved abstinence (or controlled use
without associated problems) for at least 6
months. Occasional lapses, not days of
problematic use, are allowed.

n In remission or recovery: No problems related to
substance use for more than 1 year and is no
longer in any type of substance abuse treatment.

Living arrangement

What was the consumer’s living arrangement on the last

day of the quarter? These data give your agency an
ongoing record of the consumer’s residential status.

n Not applicable or unknown

n Psychiatric hospital: Those hospitals, both public
and private, whose primary function is treating
mental disorders. This includes state hospitals
and other freestanding psychiatric hospitals.

n Substance use hospitalization: Those hospitals,
both public and private, whose primary function
is treating substance use disorders.

n General hospital psychiatric ward: Psychiatric wards
located in general medical centers that provide
short-term, acute crisis care.

Evaluating Your Program 77 Appendix H: Instructions for the Outcomes Report Form

n Nursing home: Facilities that are responsible for
the medical and physical care of consumers and
have been licensed as such by the state.

n Family care home: Consumers live in single-family
dwellings with non-relatives who provide
substantial care. Substantial care is determined
by the degree to which non-relatives are
responsible for the daily care of consumers. Such
things as medication management,
transportation, cooking, cleaning, restrictions on
leaving the home, and money management are
considered. Non-relatives may have guardianship
responsibilities. If consumers are unable to do
most daily living tasks without the aid of
caretakers, consider caretakers to be providing
substantial care.

n Lives with relatives (heavily dependent for personal
care): Consult consumers and relatives about how
much family members are responsible for
consumers’ daily care. An important distinction
between this status and supervised apartment
program is to ask, “If the family were not
involved, would the consumer be living in a
more restrictive setting?” In assessing the extent
to which family members provide substantial
care, consider such things as taking medication,
using transportation, cooking, cleaning, having
control of leaving the home, and managing
money. If consumers are unable to
independently perform most daily living
functions, consider family members to be
providing substantial care.

n Group home: A residence that is run by staff who
provide many functions (shopping, meal
preparation, laundry, etc.) that are essential to
living independently.

n Boarding house: A facility that provides a place to
sleep and meals but it is not seen as an extension
of a mental health agency nor is it staffed with
mental health personnel. These facilities are
largely privately run and consumers have a high
degree of autonomy.

n Supervised apartment program: Consumers live
(fairly independently) in an apartment sponsored
by a mental health agency. In determining
whether someone fits this category, look at the
extent to which mental health staff have control
over key aspects of the living arrangements.

Example characteristics of control include
the following:

The mental health agency signs the lease.

The mental health agency has keys to the
house or apartment.

Mental health agency staff provides onsite day
or evening coverage.

The mental health agency mandates that
consumers participate in certain mental health
services—medication clinic, day program,
etc., to live in the house or apartment.

Note: Consumers who receive only case
management support or financial aid are NOT
included in this category; they are considered to
be living independently.

n Lives with relatives (but is largely independent): An
assignment to this category requires having
information from consumers and families. The
key consideration relates to the degree to which
consumers can perform most tasks essential to
daily living without being supervised by family
members.

n Living independently: Consumers who live
independently and are capable of self-care,
including those who live independently with case
management support. This category also
includes consumers who are largely independent
and choose to live with others for reasons
unrelated to mental illness. They may live with
friends, a spouse, or other family members. The
reasons for shared housing could include
personal choice related to culture or financial
considerations.

n Homeless: Consumers who lack a fixed, regular,
and adequate nighttime residence.

n Emergency shelter: Temporary arrangements due
to a crisis or misfortune that are not specifically
related to a recurrence of the consumer’s illness.
While many emergency shelters provide
emotional support, the need for emergency
shelter is due to an immediate crisis unrelated to
the consumer’s mental illness.

n Other: Those who complete the form should
clearly define this status in the space provided.

Appendix H: Instructions for the Outcomes Report Form 78 Evaluating Your Program

Educational status

What was the consumer’s educational status on the last day

of the quarter? These data give your agency an ongoing
record of the consumer’s educational status.

n Not applicable or unknown

n No educational participation: Consumer is not
participating in educational activities.

n Avocational/educational involvement: Organized
classes in which consumers enroll consistently
and expect to take part for the purpose of life
enrichment, hobbies, recreation, etc. These
classes must be community-based, not run by
the mental health center. Classes are those in
which anyone could participate, not just
consumers. If any of these activities involve
college enrollment, use the categories below.

n Pre-educational explorations: Consumers in this
status are engaged in educational activities with
the specific purpose of working toward an
educational goal. This includes consumers who
attend a college orientation class with the goal of
enrolling, meet with the financial aid office to
apply for scholarships, or apply for admission to
enroll. This status also includes consumers who
attend a mental health center-sponsored activity
focusing on an educational goal (for example,
campus visits with a case manager to survey the
location of classrooms; meetings with the case
manager and college staff to secure
entitlements).

n Working on General Educational Development (GED)

diploma: Consumers who are taking classes to
earn their GED diploma.

n Working on English as Second Language:
Consumers who are taking classes in English as a
Second Language in a community setting.

n Basic educational skills: Consumers who are taking
adult educational classes focused on basic skills,
such as math and reading.

n Attending vocational school or apprenticeship,

vocational program, or attending high school:

Consumers who are––

Participating in community-based vocational
schools;

Learning skills through an apprenticeship,
internship, or in a practicum setting;

Involved in on-the-job training to acquire
more advanced skills;

Participating in correspondence courses
which lead to job certification; and

Young adults attending high school.

n Attending college: 1 to 6 hours: Consumers who
attend college for 6 hours or fewer per term.
This status continues over breaks, etc., if
consumers plan to continue enrollment. This
status suggests that consumers regularly attend
college and includes correspondence, TV, or
video courses for college credit.

n Attending college: 7 or more hours: Consumers
attend college for 7 or more hours per term.
This status continues over breaks, etc., if
consumers plan to continue enrollment.

Regular attendance with expectations of
completing course work is essential for
assignment to this status.

n Other: Those who complete the form should
clearly define this status in the space provided.

Evaluating Your Program 79 Appendix I: Assessor Training

Evaluating Your Program

Appendix I: Assessor Training
and Work Performance Checklist

Evaluating Your Program 81 Appendix I: Assessor Training

Assessor Training and Work Performance Checklist

Assessment date

Assessor’s name ____________________________________________________________________ _________________________________
First Middle Initial Last Title

Agency visited _______________________________________________________________________________________________________

Agency address _______________________________________________________________________________________________________
Street

_______________________________________________________________________________________________________
City State ZIP code

EBP assessed _______________________________________________________________________________________________________

Assessor qualifications

Yes

q 1a. Data collection and skills: Assessor’s skills are evidenced by his or her prior work experience, credentials,
or supervisor’s observations.

q 1b. EBP knowledge: Assessor’s knowledge is evidenced by his or her prior work experience, credentials,
or passing a knowledge test on a specific EBP.

q 1c. Training: Assessors receive at least 8 hours of systematic training on chart review, interviewing techniques,
and process assessment.

q 1d. Shadowing: Assessors complete at least 1 assessment with an experienced assessor before the first official
process assessment.

q 1e. Practice rating: Assessors co-rate as practice before being official assessors and agree exactly
with an experienced assessor on ratings for at least 80% of items.

/5 Subtotal

Data Collection

/ /

Appendix I: Assessor Training 82 Evaluating Your Program

q 2a. Contact and scheduling: With contact person, assessors identify a date convenient to site, explain
purpose of the assessment, identify information to be assembled ahead of time, and develop specific
schedule of interviews and assessment activities.

q 2b. Number of assessors: Two or more assessors are present during the assessment visit and independently
rate all items. If agency is working with a consultant, assessor may join with consultant to conduct
assessments.

q 2c. Time management: Sufficient time is allotted and all necessary materials reviewed (2 days for 2
assessors).

q 2d. Interviewing: Interview all the sources stipulated in the protocol (e.g., for IMR, interviews with the
program director, 3 ACT team members, and 3 consumers).

q 2e. Completion of documents: Complete score sheet, cover sheet, and any other supplemental documents
relating to the agency.

q 2f. Documentation supporting rating: Each assessor provides written documentation for evidence
supporting the rating for each item (e.g., marginal notes).

q 2g. Chart selection and documentation: Chart selection follows guidelines provided in the protocol
(e.g., randomized, appropriate type and number of charts). Assessors note discrepancies (e.g., chart
unavailability).

q 2h. Chart review: Both assessors review all charts and rate them independently.

q 2i. Resolution of discrepancies: When a discrepancy exists between sources (e.g., charts and ACT team
members), assessors make followup probes with an appropriate informant (typically the ACT leader
or relevant staff members).

q 2j. Independent ratings: No later than 1 day after the assessment, assessors independently complete scales
before discussing ratings.

/10 Subtotal

Post-assessment visit

q 3a. Timely consensus: Within 5 working days after the assessment, assessors discuss their ratings
to determine consensus ratings, identifying any followup information needed. A third assessor
(e.g., supervisor) may be consulted to resolve difficult ratings.

q 3b. Inter-rater reliability: Raters agree exactly on ratings for at least 80% of the items. Sources of
unreliability are discussed with supervisor and strategies developed to reduce future unreliability.

q 3c. Follow up on missing data: If followup calls are needed to complete an item, information obtained
within 3 working days.

/3 Subtotal

Comprehensive report writing

Evaluating Your Program 83 Appendix I: Assessor Training

q 4a. Documentation of background information:

n List recipients of report in the header (usually the agency director and ACT leader;
add others by mutual agreement).

n Summarize time, place, and method.

n Provide background about scale.

q 4b. Site and normative fidelity data: Provide a table with item-level (consensus) scores, along with
normative data (if available). Normative data include both national and State norms. In this table, provide
comparative site data from prior assessments. On second and later assessments, provide a graph of global
fidelity ratings over time for the site (trend line).

q 4c. Quantitative summary: Provide narrative summary of quantitative data. List strengths and weaknesses.

q 4d. Score interpretations:

n Interpret overall score.

n Include other pertinent observations.

n Provide overall summary.

n Provide opportunity for site to comment and clarify.

q 4e. Report editing: If agency is working with a consultant, consultant may write report. Assessor and
supervisor review draft of the report before it is submitted to the agency.

/5 Subtotal

Report submission and followup

q 5a. Timely report: Report sent to agency director within 2 weeks of visit.

q 5b. Follow up on report: If agency is working with a consultant, consultant discusses report with designated
agency staff within 1 month of assessment.

/2 Subtotal

Quality control

q 6. Quality control: Supervisor reviews assessments and gives feedback, as necessary, to assessors.
Depending on skill level of assessors, supervisor periodically accompanies assessors on assessment
for quality assurance purposes.

/1 Subtotal

/27 Total — Add the subtotals.

HHS Publication No. SMA-09-4422
Printed 2009

26173.0709.7765020404

Cover
• Title Page

Acknowledgments
Evaluating Your Program

• What’s in Evaluating Your Program

Why Evaluate Your Family Psychoeducation Program?
Why you should collect process measures
Why you should collect outcome measures
Why develop a quality assurance system
Conduct a Readiness Assessment
Readiness Assessment
Conduct Process Assessments
How to use process measures
Monitor Outcomes
Develop procedures
What Is the Consumer Outcomes Monitoring Package?
Expanding Your Outcome Measures
Use Data to Improve Your Program

• Appendix A: Cover Sheet- Family Psychoeducation Fidelity Scale and General Organizational Index
• Appendix B: Checklist- Observation of Multifamily Group Sessions
• Appendix C: Family Psychoeducation Fidelity Scale and Score Sheet
• Appendix D: Family Psychoeducation Fidelity Scale Protocol
• Appendix E: General Organizational Index and Score Sheet

Appendix F: General Organizational Index Protocol
Appendix G: Outcomes Report Form
Appendix H: Instructions for the Outcomes Report Form

• Appendix I: Assessor Training and Work Performance Checklist

A Road Map to Implementing
Evidence-Based Programs

June 2012

Table of Contents

Course Overview ………………………………………………………………………….. 3

About this Course …………………………………………………………………….. 3

Intended Audience ……………………………………………………………………. 3

What to Expect………………………………………………………………………… 3

Course Topics …………………………………………………………………………. 4

Course Learning Objectives …………………………………………………………. 4

Implementation Language ……………………………………………………………..5

The Five Stages of Implementation ………………………………………………….7

Exploration: Getting Started……………………………………………………………8

Identifying Community Needs………………………………………………………. 8

Assessing Organizational Capacity…………………………………………………. 9

Searching Program Registries to Select the Right Program ………………….. 11

Understanding Program Fidelity and Adaptation ………………………………. 12

Installation: Launching Your Program……………………………………………. 13

Initial Implementation: Expect the Unexpected ………………………………. 15

Full Implementation: The Program is in Place …………………………………. 16

Program Sustainability: Maintaining Your Program’s Success……………. 18

Contact Us …………………………………………………………………………………. 19

Appendix A – Resources ………………………………………………………………. 20

Appendix B – References ……………………………………………………………… 24

Appendix C – Supplemental Documents …………………………………………. 25

Course Overview

About this Course

This course provides guidance to facilitate selection and implementation of one of

the many evidence-based programs related to prevention and treatment that are

publicly available today. You will learn how to (1) select the program that best

matches your organization’s needs and (2) carry out the steps necessary to

implement the program you choose

.

Intended Audience

Individuals who may benefit from this course include members of an organization

working collaboratively to identify and implement an evidence-based

program.

Whether you’re looking for a program that addresses bullying, underage drinking,

drug abuse, or treatment of a specific mental health disorder, the information here

can help you in the selection and implementation of a suitable program. Those who

may find the course useful are:

 Administrators, program directors, or clinicians charged with identifying,

selecting, and implementing a program to meet the needs of their target

population, funders, community, etc.

 Individuals interested in learning more about best practices and strategies for
successful program selection and

implementation

What to Expect

This course provides overall guidance for appropriately selecting and implementing

the program of your choice. The focus is not on individuals choosing a program, but

rather on an organization working collaboratively to select and implement a

program to fit its needs. Experience has shown that organizational commitment,

readiness, and flexibility are all critical to successful selection and implementation

of an evidence-based program or practice.

This course includes several components. A section on terminology will introduce

you to some of the language you may encounter during your program selection and

implementation tasks. A glossary is also available if you need it. Each page is

supplemented with links to other resources that may prove helpful to your learning

experience. The information presented here has been distilled from professional

publications, and full references appear at the end.

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Course Topics

The following topics are covered in this course:

1. Course Overview

2.

Implementation Language

3. Five Stages of Implementation

4.

Exploration: Getting Started

5.

Installation: Launching Your Program

6.

Initial Implementation: Expect the Unexpected

7.

Full Implementation: The Program is in Place

8. Program Sustainability: Maintaining Your Program’s Success

Course Learning Objectives

This course will help you learn:

 Basic terms related to program selection and implementation

 How to identify your organization’s needs

 Where to find available programs

 How to select the best program for your organization’s needs, with a focus on

implementation

 The five basic stages of program implementation

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Implementation Language

This section will introduce you to some of the terms used in the field of

implementation science and research.

To begin, the general term program, as used in this course, refers to an

intervention designed to bring about specific outcomes for specific purposes or

populations. An example would be a program based on scientific principles designed

to prevent drug abuse by children.

Implementation refers to putting the program — and the scientific principles — to

work in a real setting, such as a school or community to bring benefits to a

particular target audience.

Dissemination of programs refers to the targeted distribution of information and

program materials to a specific public health or clinical practice audience. The intent

is to spread knowledge about the programs and encourage their use.

Increasingly, the approach to prevention and treatment includes the use of

evidence-based programs and practices. Evidence-based signifies that the

approach is based in theory and has undergone scientific evaluation. This contrasts

with approaches based on tradition, convention, belief, or anecdotal evidence. The

shift to evidence-based programs seeks to enhance the potential for positive

results. Today, many foundations, government agencies, and state legislatures

encourage or require the use of evidence-based programs in service delivery plans.

Evidence-based programs are designed by program developers such as researchers

at universities, practitioners in the field, and businesses engaged in promoting and

distributing social services

programs.

Many evidence-based programs contain a defined set of core components, which

are the essential parts of a program. Some sample core components might be:

 There are five lessons of 30 minutes each that cover five specific themes.

 Sessions are conducted with a group of four to six elementary school

students.

 The intervention is delivered in the home during home visits.
 The intervention is delivered in a specific sequence of stages.

In the above example, if you decide to change the length or frequency of the

lessons, or you use the program with a group of 12 middle school students, or you

conduct the program in a classroom instead of at home, or you change the order in

which the core components are introduced to the target population, you have

changed the core components, and you are no longer implementing the program

with fidelity. As a result, you cannot expect the same outcomes the developer

predicted.

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So, the term fidelity refers to including all the core components of a program

during implementation to help ensure successful outcomes. The term adaptation

refers to the process of changing a program to meet specific needs. If you adapt a

program for any reason, you must maintain the core components to ensure

success. Adaptation will be discussed in more detail later.

Selecting a program for implementation in your setting involves careful planning,

community and organizational involvement, and a comprehensive assessment of

resources. Once this process is completed, you are ready to determine program fit.

Program fit can be described as the (potential) match between your community’s

needs, resources, and capacity to implement a program—with the requirements of

the program.

A critical piece of implementing any program or practice is the ability to measure

the effect of the program on the population you are serving. In an outcome

evaluation, it is important to use outcome measures: How is the system

performing? What is the impact or result on what you are trying to change? In a

process evaluation, use process measures: Are the parts/steps in the system

performing as planned?

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The Five Stages of Implementation

Successfully implementing a program that fits your organization’s needs is a

process – not a single event – that occurs in multiple stages of planning, purposeful

action, and evaluating.

It is not enough to simply select a proven evidence-based program and assume

success will automatically follow. Good implementation strategies are essential.

The National Implementation Research Network (NIRN)
1

reviewed more than 2,000

articles on the

implementation of

programs and identified

five main stages of

successful

implementation (Fixsen,

Naoom, Blase, Friedman,

& Wallace, 2005), which

are all interrelated:

1
National Implementation Research Network (NIRN) – http://nirn.fpg.unc.edu

 Exploration

 Installation

 Initial Implementation

 Full Implementation
 Program

Sustainability

Since the stages are connected, issues addressed (or not addressed) in one stage

can affect another stage. Moreover, changes in your organization or community

may require you to revisit a stage and address activities again to maintain the

program.

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Exploration: Getting Started

The goal of the Exploration Stage is to select the right evidence-based program.

Your organization will strive to identify the best program fit, which is the match

between needs and resources and the characteristics of the program (this is

discussed in greater detail later). Four main activities are involved in this stage:

 Identify your community’s needs to determine the type of program that

will be most appropriate.

 Assess your organizational capacity including financial resources,

organizational commitment, and community buy-in to determine your ability

to implement a program with fidelity.

 Search program registries to select a program that matches your

community needs, your organization’s available resources, and available

programs.

 Understand program fidelity and program adaptation.

Focusing on these activities to identify a good program fit is part of ensuring

successful implementation.

Identifying Community Needs

Much has been written about the importance of the community needs assessment.

Identifying your target population and understanding its needs, challenges, and

assets is critical to your success in choosing an appropriate program. Articulating

the outcomes you want to achieve (such as reducing underage alcohol use or

improving parental bonding) will provide the framework for exploring the range of

evidence-based programs and practices and selecting the best fit for your

organization.

See Community Needs Assessment Resources and Tools
2

for more information on

community needs assessments.

2
See Appendix A

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Assessing

Organizational Capacity

Financial and Personnel Costs

Programs cost money. You will likely need program-specific materials to implement

the program (manuals, materials, etc.). However, implementing a new program

may also require additional funds to hire new staff or purchase needed equipment

or space. Contact the developer to discuss the program you are considering. The

developer can clarify basic information such as costs, time needed, what to expect,

etc. You also need to clearly identify your financial and staff and community

resources. Do you have space available? Do you have the funding you need to fully

implement the program? How much will the program itself cost? The program

developer often indicates in the program materials how much it will cost for staff

training, materials, additional equipment, technical assistance support, and all other

costs directly associated with the program. Ask the program developer about these

implementation costs and the cost of service delivery (how a program bills for the

services it provides), if appropriate.

There may also be other less obvious costs to consider related to infrastructure. For

example, if the program indicates the need for staff with specific skills (such as

someone with a master’s degree in social work), you will need to consider the skills

of your current staff members and determine if you need to hire someone new or

train a current staff person. If the program requires that all staff members have

access to a computer program or an Internet connection, additional funds may be

required to make such resources available. It is also important to pay attention to

caseload standards as many evidence-based programs require a specific caseload

that may be dramatically different from usual care. The overall size and scope of

the chosen program will influence the potential associated costs of implementing it.

 Questions To Ask: Financial and Personnel Resources3

 See Organizational Capacity Resources and Tools4 for more information on
organizational capacity.

3
See Appendix C

4
See Appendix A

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Commitment and Buy-In

Your organization’s staff at all levels will need to be committed to the

implementation process for the long term. It may take one to four years to

implement a program and achieve positive outcomes, and the process will continue

throughout the life of the program. Discussions — and commitments — are
extremely important.

It is also important to understand that achieving buy-in is not a one-time event.

Those in positions of leadership, who often make program decisions, and also the

practitioners, support staff, and human resources staff will need to stay committed

to facilitating delivery of the program and eliminating barriers to success.

 Questions To Ask: Commitment and Buy-In5

 See Organizational Capacity Resources and Tools6 for more information on
organizational capacity.

5
See Appendix C

6
See Appendix A

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Searching Program Registries to Select the Right Program

Once you have a clear idea of your program needs and your organizational

resources, you may search registries of programs to select a program that matches

your needs. It is important to read and understand the criteria used to rate or

classify programs as these will differ by source. Registries and other resources may

also be specific to certain topics or service areas such as education, mental health,

juvenile justice, etc.

The Center for Substance Abuse Prevention (CSAP) provides a checklist of

questions (CSAP, 2009) you may ask to see how well your potential selection might

fit your needs:

 Questions To Ask: Center for Substance Abuse Prevention (CSAP)’s Checklist

for Program Fit
7

 See Program Registries Resources and Tools8 for more information on
program registries.

7
See Appendix C

8
See Appendix A

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Understanding Program

Fidelity and Adaptation

Two especially important concepts introduced earlier in the section on

implementation language are program fidelity and program adaptation. It is

common for an organization to decide to “adapt” a program at the time of selection

(that is, change it to fit its needs) rather than plan to implement the program with

fidelity (that is, as it was designed by the program developer). Typically,

organizations want to change either (1) the program’s content or (2) the mode of

delivery.

You may choose to adapt a program for a variety of reasons, such as

 Differences in the target population: for example, your organization may be

looking for a program suitable for a Latino population and find a good

program that is not specifically targeted to Latinos; you might consider

adjusting the program to serve that community

 Issues with complexity or ease of use: for example, a teacher may want to

deliver a certain classroom-based program, but class time is not long enough

 Potential barriers to implementation such as time, money, resources, or

accessing the target population

 Lack of perceived efficacy, relevance, or acceptance of the program

 Lack of understanding of what makes the program work

Please be cautioned that your adaptations may have implications that will affect the

program’s results. Many believe adapting a program is the easier route for

achieving desired outcomes, but the opposite is often true. Adapting an intervention

so that it meets the needs of a certain target population requires a thorough

understanding of the program theory and the components mentioned earlier.

Adapting a component of a program without understanding the underlying rationale

may result in undesired or unintended program outcomes. Once adaptations have

been made (without input from the program developer), you cannot expect to see

the outcomes produced by the original.

Adapting a program may also require additional resources (personnel, time, and

funds) to monitor the adaptation and evaluate the outcomes. Program adaptations

may be necessary, but they will require additional planning and evaluation above

and beyond implementation with fidelity.

See Fidelity and Adaptation Resources and Tools
9

for more information on fidelity

and adaptation.

9
See Appendix A

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Installation: Launching Your Program

Once a program has been selected and materials purchased, the process of

installing a program begins. Installation refers to making the structural and

instrumental changes necessary to implement the program within an organization.

Establishing an Implementation Team within your organization will be critical at this

stage. The Implementation Team is a core set of individuals charged with

providing guidance through full implementation of the program. This team helps

ensure engagement of the stakeholders, creates readiness for implementation,

ensures fidelity to the program, monitors outcomes, aligns systems, and removes

barriers to implementation. An organization can choose to develop the

Implementation Team during the Exploration Stage; however, the participants may

change as you move into the Installation Stage.

The following are typical tasks to be conducted during this stage:

 Establish space in the organization for the program, including both physical

space and process space.

 Develop easily accessible data systems to collect and measure the effects of

the program and the

process.

 Install and debug any needed equipment (e.g., software).

 Interview current staff to ensure a match with needed qualifications.

 Recruit, select, and hire additional staff as needed.

 Train staff to use the program and any new systems or equipment needed to
implement the program.

Best Practices

The following are best practices for the Installation Stage:

 Establish an Implementation Team.
o A strong understanding of the program to be implemented
o Knowledge of how to successfully implement the program with fidelity
o An ability to become more effective and efficient over time through

experience

 Identify and engage an individual or group of individuals to
“champion” or promote your chosen program.

o Look for people within the organization and the community who are
influential, respected, and committed to the program. These people
must have the ability to identify problems that arise and to propose

solutions to support and ensure the success of the program. These

individuals should be active participants in the implementation process

and involved with or be members of the Implementation Team.

 Budget for startup costs.

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o Since installation occurs prior to the provision of the new service,
funds will be expended that are not reimbursable or covered through

other funding mechanisms.
 Recognize and address issues regarding readiness.

o Individuals do not adapt to change in the same way or along the same
time line. Preparing for change and recognizing change occurs in

stages leads to a supportive climate for implementation.

Potential Challenges

The following are potential challenges during the Installation Stage:

 The organization will be spending money before new services are being
provided.

 The “status quo” or “business as usual” attitudes and behaviors will be
challenged and can cause discomfort and disruption.

 A deeper understanding of the challenges of implementing the new program
may surface as practitioners, staff, and leadership individuals are asked to

change behaviors and processes.

The new program may cause disequilibrium in the system. For example, many

agencies and partners will be affected as new services are provided, particularly

with respect to referral procedures.

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Initial Implementation: Expect the Unexpected

During the initial implementation stage, individuals begin to put into practice all

that has been planned for during exploration and installation. Practitioners and staff

will be changing their behavior, using new skills for the first time, and incorporating

new practices into their everyday routine.

This stage is often awkward because people are now expected to perform new skills

and engage in new processes, which may lead them to perform in an uncoordinated

or hesitant fashion. Practicing and implementing new skills with fidelity will take

time.

Best Practices

The following are best practices for the Initial Implementation Stage:

1. Manage the Change Process. One role for the Implementation Team will

be to guide and manage the change process and help mitigate fear and

resistance. As the team works to remove barriers, it can address issues that

surface and help maintain the momentum of the initiative. The

Implementation Team can help to set realistic goals and expectations

regarding implementation progress, time lines, and the collection and use of

the right data at the right time.

2. Accept Abundant Coaching. Ongoing consistent coaching for line staff and

practitioners is critical to implementation success. A coach can be trained by

the program developer or have extensive experience implementing the

program in a similar organizational environment. A coach can provide

immediate feedback and support to practitioners and staff. Coaching

minimizes resistance, increases positive perceptions of the program and

implementation, and enhances skills development. Coaching also helps

manage expectations and normalize the implementation. Coaches may be

employed by the organization to support staff and assist with monitoring

outcomes with ongoing technical assistance.

Potential Challenges

The following are potential challenges during the Initial Implementation Stage:

 Resistance to change: Putting new and unfamiliar skills and processes to
use can be uncomfortable.

 Inertia: Program implementation may get stalled on bumps and snags along
the way, causing the initiative to lose momentum.

 Program adaptations: Discomfort and uncertainty can lead to changes to
core intervention components.

 Unrealistic expectations: Organizational leaders and funders may have
unrealistic expectations regarding implementation progress or consumer

outcomes during this stage.

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Full Implementation: The Program is in Place

Full implementation occurs when the program is integrated into the service,

organization, and system settings. The processes and procedures to provide the

selected program are now in place. For example, staffing is complete, caseloads are

full, services are being more skillfully provided by staff, and funding streams are in

place. It now becomes important to maintain and improve the program through

excellent monitoring and purposeful improvement to avoid entering program drift

(that is, edging toward a lack of fidelity). Your program or service is ready to be

evaluated, with a focus on assessing program fidelity. Fidelity measures, which can

be provided by the program developer, are commonly used at this point to

determine if the program is being delivered as intended.

After a program has been implemented with fidelity, program modifications may be

considered to help produce better outcomes. For example, if fidelity is high but

outcomes are not as expected, this may require program adaptation, an adjustment

to the program to fit the specific needs of the organization or its recipients.

All adaptations should be carried out carefully and systematically with the help of

the program developer and with attention to both process and outcome

evaluations. Process evaluation determines if the program has been implemented

as intended; for example, if you accomplished what you intended. Outcome

evaluation refers to reviewing the results to determine if the program is working for

the intended population and how this is measured. Outcome evaluation refers to

reviewing the results to determine if the program is working for the intended

population and how this is measured.

Best Practices

The following are best practices for the Full Implementation Stage:

1. Maintain and improve service, linkages, support, and infrastructure.

2. Maintain integrated, fully functioning core program components. If

adaptations must be made, engage the program developer in the adaptation

process.

3. Monitor and evaluate fidelity to ensure the program is being skillfully

delivered, using fidelity measures and indicators developed specifically for

this purpose.

Potential Challenges

The following are potential challenges during the Full Implementation Stage:

 Lack of training or failure to receive the full dosage of training intended

 Lack of required materials

 Use of some but not all of the required lessons and delivery strategies

 Failure to offer the program in the required sequence of stages

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 Failure to plan for and manage staff turnover

 Lack of adequate referrals

 Lack of time to implement the entire program

 Miscellaneous difficulties or inconveniences, such as technology or equipment

failures

 Day-to-day crises

 Failure to maintain the buy-in and support of staff, administrators, or others

Organizational issues may also contribute to this failure, such as:

 Lack of funding

 Inadequate infrastructure

 Lack of data-driven decisionmaking or autonomous decisionmaking, where

frontline staff are not communicating decisions to leadership or management

 Lack of administrative support

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Program Sustainability: Maintaining Your Program’s Success

Sustainability is only possible when full implementation has been achieved.

Sustaining change can be difficult. Your program is not frozen in time and must

adapt continually to changes in the community, funding streams, and organizational

priorities. Organizational culture, leadership, and staff need to be nurtured and

maintained. The involvement of high-level administrators in a continuous feedback

loop with the Implementation Team, providers, and recipients is critical. At this

stage, an organization should institutionalize a quality assurance mechanism to

evaluate use of data. This will facilitate assessing the effectiveness and quality of

the program.

Most importantly, sustainability can and should be planned for early in the

implementation process and examined at each stage.

“The bridge from science to service must be built, repaired, maintained, and

improved.” – NIRN Brief, January 2009

Best Practices

The following are best practices for the Program Sustainability Stage:

1. Ensure continued funding for the program and the supporting infrastructure

is built into organization’s budget.

2. Ensure fidelity to core program components.

3. Develop and implement plans for quality improvement, including regular

review of process and outcome measures and using results to improve the

program.

4. Evaluate data systems that support decisionmaking regarding the

implementation of your program’s outcomes.

5. Develop new community partnerships while maintaining existing

relationships.

6. Share positive results with staff, community and others to maintain buy-in

and support.

Celebrate success with program recipients, staff, and community.

Potential Challenges

The following are potential challenges during the Program Sustainability Stage:

 Obstacles and challenges to ongoing success can be many and varied. The

best approach is to continue to monitor results and be alert to changes that

might affect your program.

 Changes that might occur include:

o Funding levels or sources of funding

o Staff turnover

o Organizational priorities
o Organizational leadership

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Contact Us

Thank you for completing our learning module on implementation. We wish you

success in selecting and implementing the right program for your community. If

you have feedback, comments, or further questions, please Contact Us
10

.

10
Contact Us page of the NREPP website – http://nrepp.samhsa.gov/

ContactUs

.aspx

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Appendix A – Resources

Community Needs Assessment

Tools

 CDC Evaluation Working Group: Framework for Program Evaluation
http://www.cdc.gov/eval/framework/index.htm

 Child Welfare Information Builder: Evaluation Toolkit and Logic Model Builder
http://www.childwelfare.gov/preventing/developing/toolkit/

 Community Toolbox: Implementing Best Process for Community Change and
Improvement

http://ctb.ku.edu/en/promisingapproach/

 FRIENDS National Resource Center for Community-Based Child Abuse
Prevention: Evaluation Toolkit

http://www.friendsnrc.org/evaluation-toolkit

 RE-AIM: Reach, Effectiveness, Adoption, Implementation and Maintenance
Framework

http://www.re-aim.org/
 W.K. Kellogg Foundation: Evaluation Handbook

http://www.wkkf.org/knowledge-center/resources/2010/W-K-Kellogg-

Foundation-Evaluation-Handbook.aspx

 W.K. Kellogg Foundation: Logic Model Development Guide
http://www.wkkf.org/knowledge-center/resources/2006/02/WK-Kellogg-

Foundation-Logic-Model-Development-Guide.aspx

Further Reading

 Aarons, G. A., Wells, R. S., Zagursky, K., Fettes, D. L., & Palinkas, L. A.
(2009). Implementing evidence-based practice in community mental health

agencies: A multiple stakeholder analysis. American Journal of Public Health

99(11):2087-95.

 Understanding Evaluation: The way to better Prevention Programs
http://ed.gov/PDFDocs/handbook (PDF, 207KB)

Organizational Capacity
Tools

 NREPP’s Questions to Ask Program Developers
http://www.nrepp.samhsa.gov/pdfs/questions_to_ask_developers (PDF,

54KB)
 FRIENDS National Resource Center for Community-Based Child Abuse

Prevention: Integrating Evidence-Based Practices into CBCAP Programs: A

Tool for Critical Discussions–Appendix D-Implementation Plan Worksheet

http://friendsnrc.org/direct-download-menuitem/doc_download/46-

introduction-and-getting-started (PDF, 156KB)

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http://friendsnrc.org/direct-download-menuitem/doc_download/47-

appendices (PDF, 99KB)

Further Reading

 Chinman, M., Imm, P., & Wandersman, A. (2004). Getting to Outcomes ™

2004: Promoting accountability through methods and tools for planning,

implementation, and evaluation. No. TR-TR101. Santa Monica, CA: RAND

Corporation. Available at http://www.rand.org/publications/TR/TR101/ .

 Hall, G. E., Dirksen, D. J., & George, A. A. (2006). Measuring implementation
in schools: Levels of use. Southwest Educational Development Laboratory.

 Wiseman, S., Chinman, M., Ebener, P., Hunter, S., Imm, P., & Wandersman,

A. (2007). Getting to outcomes: 10 steps for achieving results-based

accountability. No. TR-TR101/2. Santa Monica, CA: RAND Corporation.

Available at http://www.rand.org/pubs/technical_reports/TR101.2/.

Fidelity and Adaptation
Tools

 California Healthy Kids Resource Center: Fidelity Guidelines and Checklists
for Research-Validated Programs

http://www.californiahealthykids.org/c/@sDGcv3s0nPHWQ/Pages/fidelity.ht

ml

 FRIENDS National Resource Center for Community-Based Child Abuse
Prevention: Integrating Evidence-Based Practices into CBCAP Programs: A

Tool for Critical Discussions

http://www.friendsnrc.org/cbcap-priority-areas/evidence-base-practice-in-

cbcap/integratingevidence-based-practice-resources

 The Chadwick Center for Children and Families: – Adaptation Guidelines for
Serving Latino Children and Families Affected by Trauma
http://www.chadwickcenter.org/WALS/wals.htm

 The Hogg Foundation for Mental Health at the University of Texas at Austin –
http://www.hogg.utexas.edu/programs_cai_bib.html#poc_ca

Program Registries

Tools

 Blueprints for Violence Prevention: Center for the Study and Prevention of
Violence

o Model Programs:
http://www.colorado.edu/cspv/blueprints/modelprograms.html

o Promising Programs:
http://www.colorado.edu/cspv/blueprints/promisingprograms.html

 California Evidence Based Clearinghouse for Child Welfare
http://www.cebc4cw.org

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 California Healthy Kids Resource Center
http://www.californiahealthykids.org/rvalidated

 Campbell Collaboration (C2)
http://www.campbellcollaboration.org/

 Center for the Study of Social Policy: Exemplary Early Childhood Programs
http://www.strengtheningfamilies.net/index.php/program_tools/change/cate

gory/learning_from_exemplary_programs/

 Coalition for Evidence-Based Policy, Social Programs that Work
http://evidencebasedprograms.org/wordpress/

 Cochrane Collaboration
http://www.cochrane.org/

 National Association of County and City Health Officials: The Model Practice
Database

http://www.naccho.org/topics/modelpractices/database/index.cfm
 National Registry of Evidence Based Programs

and Practices (NREPP)

http://

www.nrepp.samhsa.gov

 Office of Juvenile Justice and Delinquency: Model Programs Guide
http://www.dsgonline.com/mpg_non_flash/search.htm

 Promising Practices Network: Programs that Work
http://www.promisingpractices.net/programs.asp

 Public Health Agency of Canada: The Canadian Best Practices Portal
http://cbpp-pcpe.phac-aspc.gc.ca/intervention/list

 Sociometrics: Effective Programs
http://www.socio.com/effectiveprograms.php

Additional Resources

 CASEL, Safe and Sound: An Education Leader’s Guide to Evidence-Based
Social and Emotional Learning (SEL) Programs

http://www.edutopia.org/safe-and-sound-education-leaders-guide-evidence-

based-social-and-emotional-learning-sel-p

 Child Trends: Research to Improve Children’s Lives
http://www.childtrends.org/_portalcat.cfm?LID=C6CEDAFE-34FF-4DFD-

9CD745899CE5D128

 Children’s Services Council, Palm Beach County. Evidence-Based Programs
http://www.evidencebasedassociates.com/reports/research_review (PDF,

360KB)
 Department of Education’s Expert Panel on Safe, Disciplined and Drug-Free

Schools Programs

http://www.ed.gov/admins/lead/safety/exemplary01/index.html

 Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-
Centre), University of London

http://eppi.ioe.ac.uk/cms/
 FRIENDS: National Resource Center for Community-Based Child Abuse

Prevention (CBCAP): Integrating Evidence-Based Resources

http://friendsnrc.org/cbcap-priority-areas/evidence-base-practice-in-

cbcap/integrating-evidence-based-practice-resources

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 Guide to Community Preventive Services (U.S. Centers for Disease Control
and Prevention)

http://www.thecommunityguide.org/index.html
 NASMHPD Research Institute (NRI): Center for Mental Health Quality and

Accountability: Synthesis of Reviews of Children’s Evidence-Based Practices.

Prepared by Jacqueline Yannacci, M.P.P., and Jeanne C. Rivard, Ph.D., June

2005.

http://ebp.networkofcare.org/uploads/Synthesis_of_Reviews_of_the_Researc
h_on_Evidence_Based_and_Promising_Practices_9592994 (PDF, 1.6MB)

 Pew Partnership for Civic Change: Solutions for America (The Guide for Civic
Problem Solving)

http://www.solutionsforamerica.org/

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Appendix B – References

 Backer, T. E. (2001). Finding the balance: Program fidelity and adaptation in

substance abuse prevention. Rockville, MD: Center for Substance Abuse

Prevention, SAMHSA Model Programs (www.samhsa.gov).

 California Department of Education, California Department of Public Health:

California Healthy Kids Resource Center. (2010). Fidelity guidelines and

checklists for research-validated programs. Available at

http://www.californiahealthykids.org/fidelity.

 CSAP (Center for Substance Abuse Prevention). (2009). Identifying and

selecting evidence-based interventions. HHS Pub. No. (SMA) 09-4205.

Rockville, MD: U.S. Department of Health and Human Services, Substance

Abuse and Mental Health Services Administration.

 Domitrovich, C. E., & Greenberg, M. T. (2000). The study of implementation:

Current findings from effective programs that prevent mental disorders in

school-aged children. Journal of Educational and Psychological Consultation,

11(2), 193–221.

 Dusenbury, L., Brannigan, R., Falco, M., & Hansen, W. B. (2003). A review of

research on fidelity of implementation: Implications for drug abuse

prevention in school settings. Health Education Research, 18(2), 237–256.

 Elliott, D. S., & Mihalic, S. (2004). Issues in disseminating and replicating

effective prevention programs. Prevention Science, 5(1), 47–53.

 Fixsen, D. L., Blase K. A., Duda, M. A., Naoom, S. F., Van Dyke, M. (2010).

Implementation of evidence-based treatments for children and adolescents:

Research findings and their implications for the future. In J. R. Wiez and A. E.

Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents.

New York: Guidford Press.

 Fixsen, D. L., Naoom, S. F., Blase, K. B, & Wallace, F. (2007).

Implementation: The missing link between research and practice. APSAC

Advisor, 19 (1 & 2), pp. 4–11.

 Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F.

(2005). Implementation research: A synthesis of the literature. The National

Implementation Research Network. FMHI Publication #231. Tampa, FL:

University of South Florida, Louis de la Parte Florida Mental Health Institute.

o Available at http://nirn.fpg.unc.edu/

 Mowbray, C. T., Bybee, D., Holter, M., & Lewandowski, L. (2006). Validation

of a fidelity rating instrument for consumer-operated services. American

Journal of Evaluation, 27(1), 9–27.

 NCI (National Cancer Institute). (n.d.). Using what works: Adapting

evidence-based programs to fit your needs. Module 4, Making the evidence-

based program fit your needs: Adaptation and your program summary.

Glossary

http://nrepp.samhsa.gov/AboutGlossary.aspx

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Appendix C – Supplemental Documents

Questions to Ask:

 Financial and Personnel Resources

 Commitment and Buy-In

 CSAP’s Checklist for Program Fit

Questions to Ask: Financial and Personnel Resources

Recruitment/Hiring

 If you need to hire new staff, how much will it cost to recruit and fund

additional staff?

 Will you need to increase from part-time to full-time staff?

Staff Training

 How much will it cost to train staff on the new evidence-based program?

 How much will it cost to train staff on the necessary skills to support the new
evidence-based program?

Equipment and Maintenance

 What additional equipment will you need to purchase such as computers, cell

phones, furniture, telecommunication equipment, or other resources?

 What technical support will be required to maintain any new equipment?

 How much will it cost to maintain the equipment?

Facilities

 What are the space requirements to implement the new program?

 Will you need to increase your office and meeting space to accommodate

new staff or program recipients?

 Do you have the funds available to acquire any new space required?

Sustainability

 What are the long-term costs associated with maintaining the program?

 What are the long-term costs associated with maintaining the organizational
infrastructure required for implementation?

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Questions to Ask: Commitment and Buy-In

Leadership

 What is the leadership’s plan to ensure and sustain community commitment
and buy‐in?

 What barriers are anticipated that might influence program implementation

and how will these barriers be addressed, both inside and outside the

organization?

 How will leadership address possible resistance to systems change both
inside and outside the organization?

Staff/Providers

 How will all staff be engaged to work to create a hospitable environment for

a new program?

 How will staff be trained and supported to ensure and sustain commitment
and buy‐in.

Support Staff

 How will current recruitment and hiring policies be changed or addressed if

found to inhibit or delay of program implementation?

 How will the new program affect billing for new services and what systems

will be required to accommodate these changes?

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Questions to Ask: Center for Substance Abuse Prevention (CSAP)’s

Checklist for Program Fit

 Is the program appropriate for the population identified in the community

needs assessment and community logic model? Has the program been

implemented successfully with the same or a similar population? Are the

population differences likely to compromise the results?

 Is the program delivered in a setting similar to the one planned by your

community? In what ways is the context different? Are the differences likely

to compromise the program’s effectiveness?

 Is the program culturally appropriate? Did members of the culturally

identified group participate in developing it? Were program materials adapted

to the culturally identified group?

 Are program materials (e.g., manuals, procedures) available to guide

implementation? Are training and technical assistance available to support

implementation? Are monitoring or evaluation tools available to help track

implementation quality?

 Is the program culturally feasible, given the values of the community?

 Is the program politically feasible, given the local power structure and

priorities of the implementing organization? Does the program match the

mission, vision, and culture of the implementing organization?

 Is the program administratively feasible, given the policies and

procedures of the implementing organization?

 Is the program technically feasible, given staff capabilities, time

commitments, and program resources?

 Is the program financially feasible, given the estimated costs of

implementation (including costs for purchase of implementation materials

and specialized training or technical assistance)?

Thoughtful consideration and discussion of the above questions will be helpful in

identifying the right program.

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SAMHSA’s National Registry of Evidence-based Programs

and Practices (NREPP)
www.nrepp.samhsa.gov

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• TOC
• CourseOverview
• CourseTopics
• CourseLearningObjectives
• ImplementationLanguage
• TheFiveStagesofImplementation
• ExplorationGettingStarted
• IdentifyingCommunityNeeds
• AssessingOrganizationCapacity
• Searching
• ProgramRegistries
• UnderstandingProgramFidelity
• InstallationLaunchingYourProgram
• InitialImplementation
• FullImplementation
• ProgramSustainability

ContactUs

• AppendixA
• CommunityNeedsAssessment
• OrganizationalCapacity
• FidelityandAdaptation

ProgramRegistries

• AdditionalResources
• AppendixB
• AppendixC
• FinancialandPersonnelResources
• CommitmentandBuyIn
• CSAPChecklist