Hvilke familietilbud trenger de yngste

1. AFjell Haugesund sept.2009 Hvilke familietilbud trenger de yngste? Anne Fjell TIPS S�R �ST

2. AFjell Haugesund sept.2009 I en periode i livet vil det v�re av stor betydning i forhold til � f� til en god utvikling at vi har en viss mengde aktivitet. Slik vil vi vokse i forhold til ferdigheter, selvf�lelse, vi utvider nettverket v�rt og f�r slik an stadig st�rre kunnskap om verden rundt oss. Frav�ret av meningsfull stimulering vil v�re stressfylt, det f�rer til kjedsomhet, sosiale ferdigheter stagnerer likeledes, arbeidsferdigheter, frustrasjon med seg selv for manglende framskritt i livet. ET familieliv kan ogs� by p� utfordringer. En familie vil kunne tilby en beskyttelse, ogs� i forhold til de mer normale utfordringer som livet byr p�. En psykiater skrev i 1948 (60 �r siden) at pasienter ogs� har familie. I l�pet av 80 �rene ble det grundig dokumentert at familiemedlemmer til personer som utvikler an alvorlig psykisk lidelse, vil vil kunne gi betydningsfulle bidrag til bedret prognose og selv unng� de store belastningene familier ofte blir rammet av i en slik sykdomsutvikling.dette gjelder ogs� for personer som utvikler psykose eller psykoselignende symptomer.I en periode i livet vil det v�re av stor betydning i forhold til � f� til en god utvikling at vi har en viss mengde aktivitet. Slik vil vi vokse i forhold til ferdigheter, selvf�lelse, vi utvider nettverket v�rt og f�r slik an stadig st�rre kunnskap om verden rundt oss. Frav�ret av meningsfull stimulering vil v�re stressfylt, det f�rer til kjedsomhet, sosiale ferdigheter stagnerer likeledes, arbeidsferdigheter, frustrasjon med seg selv for manglende framskritt i livet. ET familieliv kan ogs� by p� utfordringer. En familie vil kunne tilby en beskyttelse, ogs� i forhold til de mer normale utfordringer som livet byr p�. En psykiater skrev i 1948 (60 �r siden) at pasienter ogs� har familie. I l�pet av 80 �rene ble det grundig dokumentert at familiemedlemmer til personer som utvikler an alvorlig psykisk lidelse, vil vil kunne gi betydningsfulle bidrag til bedret prognose og selv unng� de store belastningene familier ofte blir rammet av i en slik sykdomsutvikling.dette gjelder ogs� for personer som utvikler psykose eller psykoselignende symptomer.

3. AFjell Haugesund sept.2009 HVA M� TIL OG HVORFOR?:

4. AFjell Haugesund sept.2009 Familiens plass i et tidlig behandlingstilbud �N�r man skal f�le opp en l�pende klinisk og forskningsmessig fokus i tidlig intervensjon og den raske �kningen av verdensomfattende program for de som erfarer psykose for f�rste gang, m� utvikling av tilbud til familiene v�re en integrert del ved ethvert sammensatt behandlingsprogram���.� Addington, 2005 Mht til de p�kjenninger som utvikling av en alvorlig psykisk lidelse representerer, er det n� slik at internasjonal litteratur fremhever n�dvendigheten av � trekke inn familien i behandlingsopplegget.Mht til de p�kjenninger som utvikling av en alvorlig psykisk lidelse representerer, er det n� slik at internasjonal litteratur fremhever n�dvendigheten av � trekke inn familien i behandlingsopplegget.

5. AFjell Haugesund sept.2009 Hva �nsker pasienter og familier hjelp til i en tidlig fase av en psykoseutvikling Familiene �nsker: Undervisning St�tte Hjelp til � utvikle foreldrerollen Pasientene �nsker � v�re tilknyttet sine familier Opprettholde kontakt og sette grenser Hjelp til � snakke sammen Hjelp til � l�se problemer O`Brien 2006.

6. AFjell Haugesund sept.2009 Risikofaktorer hos personer som kan utvikle psykose Genetisk disposisjon (Tienari) Psykososialt stress (Neuchterlein & Dawson) Familie atmosf�re (Butzlaff&Hooley) Psykososialt stress er inkludert i de fleste etiologiske modeller for schizofreni, forestilt som en utl�sende faktor hos personer med en genetisk disposisjon.: Og behandlingsstudier indikerer at Psykososialt stress er inkludert i de fleste etiologiske modeller for schizofreni, forestilt som en utl�sende faktor hos personer med en genetisk disposisjon.: Og behandlingsstudier indikerer at

7. AFjell Haugesund sept.2009 Fagfeltets situasjon i fht familietilbud Veldokumentert kunnskap om familiens rolle i behandlingen Lov om pasientrettigheter Lov om psykisk helsevern Fagfeltet har forpliktelser og muligheter til � trekke familien inn Fagfeltets h�ndtering av situasjonen Det handler ikke om hvordan du har det; hvordan m�tes behovet fra familie, Hvordan ivaretas dialogen med familien Det handler ikke om hvordan du har det; hvordan m�tes behovet fra familie, Hvordan ivaretas dialogen med familien

8. AFjell Haugesund sept.2009 Familiens rolle i en tidlig fase av psykose Familien rapporterer st�rre grad av bekymring tidlig enn senere i et forl�p (Addington, 2005): Ny og ukjent problematikk Store endringer i familieklima Tap: Endret personlighet; Traume: Uforst�elig atferd

9. AFjell Haugesund sept.2009 Familiemedlemmer har ofte gode observasjoner p� hvordan atferd har endret seg under symptomutviklingen og vil ogs� ha behov for � dele hvordan denne utviklingen har p�virket familiemedlemmene ; endret kontakt, avvisning, p�fallende forestillinger,utagering med mer. �mange vil f.eks reagere p� denne ukjent og ofte skremmende utviklingen med � trekke se tilbake for � beskytte seg mot overveldende inntrykk. familiemedlemmer vil ofte befinne seg i en felle pga manglende informasjon om hva de st�r overfor og og hvordan de kan hjelpe . � og ikke minst, � bli m�tt av noen som forholder seg til den ofte negativer omsorgserfaringen i den tidligste fasen av en psykoseutvikling, vil v�re avgj�rende i forhold hvordan de vil oppleve sin situasjon senere. . Familiemedlemmer har ofte gode observasjoner p� hvordan atferd har endret seg under symptomutviklingen og vil ogs� ha behov for � dele hvordan denne utviklingen har p�virket familiemedlemmene ; endret kontakt, avvisning, p�fallende forestillinger,utagering med mer. �mange vil f.eks reagere p� denne ukjent og ofte skremmende utviklingen med � trekke se tilbake for � beskytte seg mot overveldende inntrykk. familiemedlemmer vil ofte befinne seg i en felle pga manglende informasjon om hva de st�r overfor og og hvordan de kan hjelpe . � og ikke minst, � bli m�tt av noen som forholder seg til den ofte negativer omsorgserfaringen i den tidligste fasen av en psykoseutvikling, vil v�re avgj�rende i forhold hvordan de vil oppleve sin situasjon senere. .

10. AFjell Haugesund sept.2009 Hva bekymrer/stresser foreldre i tidlig fase av en psykoseutvikling ? Negative symptomer 39% Irritabilitet 16% D�rlig hygiene 9% Kontrollsvikt 10% Hypersensitivitet 3% O`Brien, 2006 Although suprisingly no rel between criticism and outcome in the prodrome, important to understand what aspect of youths� behavior at this phase of the illness is most aggravating to caregivers. I am only presenting top 4 categories, and then making a comment re: very little irritation re: positive symptoms. The largest number of critical comments, 39%, was directed at the young person�s negative symptoms, in particular social withdrawal (7%) and lack of motivation (32%). Parents expressed frustration with the young person�s �lack of trying,� �laziness,� �failure to complete chores,� �messiness,� �difficulty getting to school on time,� and general �need for constant pushing and prodding.� Sixteen percent of the critical comments were about irritability, verbal aggression, and/or physical aggression expressed toward pets, siblings, or parents. Either poor hygiene or excessive grooming rituals were the theme of 9% of critical comments. Ten percent of the comments were about youths� self-centeredness and inability to think about others� needs and an additional 10% pertained to frustrations regarding the perceived need to �over-parent� the young person, or in other words to provide an inordinate amount of structure, support, and attention for an adolescent/young adult. Nine percent of critical remarks were regarding a strong difference of opinion between the young person and key relative about beliefs or behaviors (for example, sexuality, religion, choice of friends, bed time, etc.). A small percentage (4%) of critical comments concerned stealing. Three percent of the critical comments referred to the young person�s hypersensitivity. Surprisingly, this was the only category within the positive symptom domain that received spontaneous criticism. --> This information helps us to identify targets of intervention - these are the issues that are most aggravating from the parents� perspective. How can they and young person cope with these challenges most effectively??? Although suprisingly no rel between criticism and outcome in the prodrome, important to understand what aspect of youths� behavior at this phase of the illness is most aggravating to caregivers. I am only presenting top 4 categories, and then making a comment re: very little irritation re: positive symptoms. The largest number of critical comments, 39%, was directed at the young person�s negative symptoms, in particular social withdrawal (7%) and lack of motivation (32%). Parents expressed frustration with the young person�s �lack of trying,� �laziness,� �failure to complete chores,� �messiness,� �difficulty getting to school on time,� and general �need for constant pushing and prodding.� Sixteen percent of the critical comments were about irritability, verbal aggression, and/or physical aggression expressed toward pets, siblings, or parents. Either poor hygiene or excessive grooming rituals were the theme of 9% of critical comments. Ten percent of the comments were about youths� self-centeredness and inability to think about others� needs and an additional 10% pertained to frustrations regarding the perceived need to �over-parent� the young person, or in other words to provide an inordinate amount of structure, support, and attention for an adolescent/young adult. Nine percent of critical remarks were regarding a strong difference of opinion between the young person and key relative about beliefs or behaviors (for example, sexuality, religion, choice of friends, bed time, etc.). A small percentage (4%) of critical comments concerned stealing. Three percent of the critical comments referred to the young person�s hypersensitivity. Surprisingly, this was the only category within the positive symptom domain that received spontaneous criticism. --> This information helps us to identify targets of intervention - these are the issues that are most aggravating from the parents� perspective. How can they and young person cope with these challenges most effectively???

11. AFjell Haugesund sept.2009 Personens symptomatferd induserer angst, sinne, sosial tilbaketrekking, forvirring hos familie og andre n�re omsorgspersoner. Familiemedlemmers reaksjoner trigger s�rbarheten / forsterker symptomutviklingen en metaoversikt over betingelser for utskrevne pasienter viser at over 60% blir utskrevet til n�re familie Utskrevet til mor, vil mange si. Det er derfor viktig � forst� hva det er som er belastende i en familie n�r man skal bidra med hjelp. Manglende forst�else for hva som skjer, er sentralt, og som ligner p� den situasjonen vi alle har v�rt i . � Bisarr atferd og uforst�elig tilbaketrening viser seg en den st�rste stressfaktoren i en familie med et psykotisk familiemedlem. en metaoversikt over betingelser for utskrevne pasienter viser at over 60% blir utskrevet til n�re familie Utskrevet til mor, vil mange si. Det er derfor viktig � forst� hva det er som er belastende i en familie n�r man skal bidra med hjelp. Manglende forst�else for hva som skjer, er sentralt, og som ligner p� den situasjonen vi alle har v�rt i . � Bisarr atferd og uforst�elig tilbaketrening viser seg en den st�rste stressfaktoren i en familie med et psykotisk familiemedlem.

12. AFjell Haugesund sept.2009 Kilder til stress Store begivenheter- negative og positive Daglige uenigheter/krangler Negative f�lelsesmessige erfaringer Relasjonsbrudd Kjedsomhet Negative emotional experiences: arguments with a girlfriend, boyfriend, friend, teacher, brother, sister, parent, etc. - interpersonal experiences; or experiences in the achievement realm - not doing as well as one had hoped on a test, in a course, on a project at work, etc. Social Disruptions - going on vacation - Now who would think that going on vacation or having friends or family come to visit would be stressful�.but it involves a lot of change to one�s daily routine - ; similarly, going off to college, moving, transitions such as from school routine to a summer routine, then from summer routine back to a school routine - ; Air travel - disruption in routine, sometimes time zone, etc. having a friend move away Boredom can be stressful too! So there are many potential sources of stress. Of course, people vary in terms of what they perceive as stressful. We think that it is really important that we all get to be really good at knowing what is stressful for us, and trying as best we can to anticipate stressful events and to plan for them. Also, we think it is important to develop a broad array of coping skills so that we are prepared to deal as effectively as possible with the stress that will inevitably come our way. Negative emotional experiences: arguments with a girlfriend, boyfriend, friend, teacher, brother, sister, parent, etc. - interpersonal experiences; or experiences in the achievement realm - not doing as well as one had hoped on a test, in a course, on a project at work, etc. Social Disruptions - going on vacation - Now who would think that going on vacation or having friends or family come to visit would be stressful�.but it involves a lot of change to one�s daily routine - ; similarly, going off to college, moving, transitions such as from school routine to a summer routine, then from summer routine back to a school routine - ; Air travel - disruption in routine, sometimes time zone, etc. having a friend move away Boredom can be stressful too! So there are many potential sources of stress. Of course, people vary in terms of what they perceive as stressful. We think that it is really important that we all get to be really good at knowing what is stressful for us, and trying as best we can to anticipate stressful events and to plan for them. Also, we think it is important to develop a broad array of coping skills so that we are prepared to deal as effectively as possible with the stress that will inevitably come our way.

13. AFjell Haugesund sept.2009 Symptomer i prodromal og pre-behandlings fasen Angst 77% Depressiv stemning 63% Sinne eller irritasjon 53% Sosial tilbaketrekning 83% Funksjonssenkning p� skole 70% Corcoran et al. 2007 Dette er hva familiemedlemmer til 13 pasienter i en kvalitativ studie fra 2007 ved New York State Psychiatric Institute svarte mht hva slags endringer de hadde observert hos sine familiemedlemmer.Dette er hva familiemedlemmer til 13 pasienter i en kvalitativ studie fra 2007 ved New York State Psychiatric Institute svarte mht hva slags endringer de hadde observert hos sine familiemedlemmer.

14. AFjell Haugesund sept.2009 Fagfeltets anbefalinger PORT; 2003, Psykoedukative flerfamiliegrupper O`Brien, 2006, Fjell 2006 Psykoedukative enfamilie tilbud Addington 2005 Bruk av familiens egne historier Birchwood 2001 Ingen agenda/ �Streng struktur�Ingen agenda/ �Streng struktur�

15. AFjell Haugesund sept.2009 Hva er virksomt; psykoedukativ familiearbeid. Undervisning; Forst�else Strukturert probleml�sning Kommunikasjonstrening Nettverksarbeid Lehman , 2003

16. AFjell Haugesund sept.2009 Hvordan m�te familienes behov: Samtaler uten pasient; Gjennomgang av egen situasjon Samtaler om tanker og holdninger omkring: utl�sende situasjon, tanker, f�lelser handling; mestring av situasjonen Hjelp til � knytte alternativ forst�else og tenkning inn i hverdagen Gradvis bruk av en ny forst�else St�tte til bruk av denne i probleml�sning av dagligdagse utfordringer sammen med sitt familiemedlem

17. AFjell Haugesund sept.2009 Konfliktfyllt samhandling Uenighet Kritiske kommentarer Irritasjon/konflikt Gr�t Tilbaketrekning Grenseoverskridelser Intraclass correlations ranged from .50 - .85 on all codes The conflict codes is a summation of the following 6 codes which capture statements that indicate disagreement, criticism, irritation, distress, or intrusiveness. Disagree - Remember that time we went to Hawaii? �Yes I hated that trip.� Critical Comment - �you are boring� �you don�t acknowledge what anyone does for you and you don�t value it.� �I have high blood pressure because of you.� Conflict/Irritation - the speaker expresses some anger or irritation through tone of voice, facial expression, or hand gestures. Cry: Withdraw; someone stops the conversation abruptly; or they turn away from the other person, avert their eyes and clearly withdraw nonverbally Intrusive - one speaker asserts he/she knows how the other feels without asking, or may describe extensive self sacrifice for the good of the other in an effort to induce guilt. Intraclass correlations ranged from .50 - .85 on all codes The conflict codes is a summation of the following 6 codes which capture statements that indicate disagreement, criticism, irritation, distress, or intrusiveness. Disagree - Remember that time we went to Hawaii? �Yes I hated that trip.� Critical Comment - �you are boring� �you don�t acknowledge what anyone does for you and you don�t value it.� �I have high blood pressure because of you.� Conflict/Irritation - the speaker expresses some anger or irritation through tone of voice, facial expression, or hand gestures. Cry: Withdraw; someone stops the conversation abruptly; or they turn away from the other person, avert their eyes and clearly withdraw nonverbally Intrusive - one speaker asserts he/she knows how the other feels without asking, or may describe extensive self sacrifice for the good of the other in an effort to induce guilt.

18. AFjell Haugesund sept.2009 Behandlingsm�lsettinger i en prodromalfase Redusere omfanget av opplevd stress i en s�rbar persons liv Gi hjelp til � hente seg inn Utvikle et register av mestringsstrategier Er det noe du har lyst til � gj�re som du ikke f�r til? Vurdere bruk av medisin for � reduserer biologisk risiko Bio-psycho-social approach Become more aware of our triggers - these differ across people - ((perhaps academic situations -taking exams; for others public speaking; others going to large parties, others not being invited to large parties.)) Some additional goals at CAPPS are to reduce the amount of stress in a vulnerable individual�s life and to fortify the individual�s ability to cope with daily stress so that we can keep them under this threshold of symptom expression. Of course, no one�s life can be entirely stress free�..but we could do what we can to minimize and contain stress. Individuals and Family members can be very helpful with all of these tasks. Everyone can direct efforts toward creating a low stress environment for a vulnerable young person. Young people can develop a broad array of skills to cope with the inevitable stress that occurs in daily life and family members can support them in their efforts to develop these skills. Also, sometimes medications are useful in reducing biological risk, and we have found that medications are often most effective when psychiatrists, families, and young people are working closely together to figure out which medications and dosages work best for a particular individual. Bio-psycho-social approach Become more aware of our triggers - these differ across people - ((perhaps academic situations -taking exams; for others public speaking; others going to large parties, others not being invited to large parties.)) Some additional goals at CAPPS are to reduce the amount of stress in a vulnerable individual�s life and to fortify the individual�s ability to cope with daily stress so that we can keep them under this threshold of symptom expression. Of course, no one�s life can be entirely stress free�..but we could do what we can to minimize and contain stress. Individuals and Family members can be very helpful with all of these tasks. Everyone can direct efforts toward creating a low stress environment for a vulnerable young person. Young people can develop a broad array of skills to cope with the inevitable stress that occurs in daily life and family members can support them in their efforts to develop these skills. Also, sometimes medications are useful in reducing biological risk, and we have found that medications are often most effective when psychiatrists, families, and young people are working closely together to figure out which medications and dosages work best for a particular individual.

19. AFjell Haugesund sept.2009

20. AFjell Haugesund sept.2009 Vanlige problemstillinger Hvordan finne en venn Hvordan starter man et vennskap? Hvordan kan jeg fortsette p� skolen til tross for at jeg ikke er motivert? Hvordan kan jeg unng� � f�le meg overveldet og overstimulert p� skolen?

21. AFjell Haugesund sept.2009 Psykoedukativt familietilbud Familiemedlemmer inkluderes i et behandlingsforl�p med et ressursorientert fokus Behandlere deler forskningsbasert kunnskap om sykdommen med familiemedlemmer og pasienter Behandlere inng�r langtidsavtaler med familiene som m�tes samlet.

22. AFjell Haugesund sept.2009 Gruppe eller enfamilietilbud? Enfamilietilbud: St�rre grad av individuell oppf�lging St�rre grad av oppmerksomhet til hvert enkelt familiemedlem Flerfamilietilbud Unge mennesker erfarer at selv om de f�ler seg isolert at de ikke er alene i sitt strev De erfarer at andre talentfulle unge kjemper med sammenlignbare problemer og hjelper dem til � finne tilbake til egen styrke Foreldre og ungdom deler utfordringer, utveksler ideer og formidler resurser

23. AFjell Haugesund sept.2009 Fordeler ved PFFG Foreldre og ungdommer observerer hverandre i en sosial kontekst Ungdommene fungerer p� et h�yere niv� med foreldre tilstede Gruppemedlemmene utvikler en ansvarlighet overfor hverandre Familiemedlemmer blir ikke satt p� side linjen I forhold til � l�se problemer og videreutvikle seg L�sningsforslagene som utvikler seg i et gruppeformat ville aldri ha kommet frem i et individuelt eller tradisjonelt tilbud. Gruppeatmosf�ren er lett og det er mye godt hum�r Dette bringer fram en felles erfaring for terapeuter og familier; en tiltrengt lettelse

24. AFjell Haugesund sept.2009 Konstruktiv samhandling Positive erfaringer Felles opplevelser Meningsfulle erfaringer Ogs� vanskelige situasjoner Struktur Positive bemerkninger ; ros Positive f�lelser; atmosf�re Transcribed the interactions and then coded them. Coder would review the videotape several times with the transcript in front of them and then code floorswitch by floorswitch. In other words, if the adolescent was the first to speak, everything the adolescent said/did would be coded. Then everything the parent said/did would be coded. Codes were not mutually exclusive, so a person could be assigned multiple codes during each floorswitch. Intraclass correlations ranged from .70 - .90 on all codes The constructive behavior code is a summation of the following 7 codes which capture statements that are on task and/or supportive, and behaviors that are affectionate. Positive experience - speaker indicates having some positive shared experince with the key relative, orelaborates upon relatives� comment. �I really enjoyed that time we spent skiing in Colorado and we all sat around and played board games in the evenings.� Meaningful experience - family discusses some experience they shared together that wasn�t joyful or light. They went through some difficulty together that they felt brought them closer together - they got into a car accident or someone died - Agree - the speaker agrees with the other�s statement about a positive or meaningful experience - �yeah I liked that too�Ask - the speaker asks the other if he/she enjoyed a particular event Structure - the speaker gets the conversation organized, back on track after a tangent or conflict.Positive remark - speaker expresses praise or appreciation for a specific characteristic or behavior of theother. Positive affect - positive tough, friendly laughter, or warm smiling. Transcribed the interactions and then coded them. Coder would review the videotape several times with the transcript in front of them and then code floorswitch by floorswitch. In other words, if the adolescent was the first to speak, everything the adolescent said/did would be coded. Then everything the parent said/did would be coded. Codes were not mutually exclusive, so a person could be assigned multiple codes during each floorswitch. Intraclass correlations ranged from .70 - .90 on all codes The constructive behavior code is a summation of the following 7 codes which capture statements that are on task and/or supportive, and behaviors that are affectionate. Positive experience - speaker indicates having some positive shared experince with the key relative, orelaborates upon relatives� comment. �I really enjoyed that time we spent skiing in Colorado and we all sat around and played board games in the evenings.� Meaningful experience - family discusses some experience they shared together that wasn�t joyful or light. They went through some difficulty together that they felt brought them closer together - they got into a car accident or someone died - Agree - the speaker agrees with the other�s statement about a positive or meaningful experience - �yeah I liked that too�Ask - the speaker asks the other if he/she enjoyed a particular event Structure - the speaker gets the conversation organized, back on track after a tangent or conflict.Positive remark - speaker expresses praise or appreciation for a specific characteristic or behavior of theother. Positive affect - positive tough, friendly laughter, or warm smiling.

25. AFjell Haugesund sept.2009 PE FFG i prodrome-fasen H�y fremm�teprosent Deltagerne evaluerer denne formen for behandling som nyttig og�behagelig� Symptomreduserende Funksjons-�kende O`Brien 2005