Psychiatric Annals

CME Article 

Psychoeducation Responsive to Families (PERF): Translation of a Multifamily Group Model

David E. Pollio, PhD; Carol S. North, MD, MPE; Ashley M. Hudson, MSW; Barry A. Hong, PhD; Victoria A. Osborne, PhD; Jennifer B. McClendon, PhD

Abstract

CME Educational Objectives

  1. Understand the role that families can play as partners in psychoeducation.
  2. Examine the key features of translating a successful intervention to a new population.
  3. Describe the process through which psychiatrists and other mental health clinicians can lead a multifamily group.

To fully understand research translation efforts, it is essential to specify the key elements of the model to be translated. Conceptually, these elements include the purpose of the intervention; structural elements, eg, length of intervention; standardization; participants; and projected outcomes.

The purpose of family psychoeducation is to provide state-of-the-art education, problem-solving, coping activities, and psychosocial support.5,6 Psychoeducation, as used here, is not conceptualized as “therapy,” because the need for personal growth and change among individual group participants is indeterminate.

For the educational component, the structure of family psychoeducation requires standardization of the educational materials in a consistent format with manualization of group procedures. Further, family psychoeducation, as opposed to education-focused models, is not a brief model. Although recommendations for optimal duration vary, and briefer models have been tested, a determined number of group sessions across a number of months (generally 6 months or more) is considered an essential part of the family psychoeducation model.7

Abstract

CME Educational Objectives

  1. Understand the role that families can play as partners in psychoeducation.
  2. Examine the key features of translating a successful intervention to a new population.
  3. Describe the process through which psychiatrists and other mental health clinicians can lead a multifamily group.

To fully understand research translation efforts, it is essential to specify the key elements of the model to be translated. Conceptually, these elements include the purpose of the intervention; structural elements, eg, length of intervention; standardization; participants; and projected outcomes.

The purpose of family psychoeducation is to provide state-of-the-art education, problem-solving, coping activities, and psychosocial support.5,6 Psychoeducation, as used here, is not conceptualized as “therapy,” because the need for personal growth and change among individual group participants is indeterminate.

For the educational component, the structure of family psychoeducation requires standardization of the educational materials in a consistent format with manualization of group procedures. Further, family psychoeducation, as opposed to education-focused models, is not a brief model. Although recommendations for optimal duration vary, and briefer models have been tested, a determined number of group sessions across a number of months (generally 6 months or more) is considered an essential part of the family psychoeducation model.7

Family psychoeducation is designed to support and educate the families of those affected by mental illness.1 A synthesis of findings from more than 30 randomized control trials concluded that family psychoeducation may reduce hospital readmission rates for people with schizophrenia and schizoaffective disorder; improve recovery among individuals with bipolar disorder; and provide support to family members by enhancing their knowledge base and sense of self-efficacy.2 Psychoeducation models for severe mental illness in adults have been successfully implemented for populations in other settings, such as the Veterans Administration (VA).3


One psychoeducation model that has been translated for use in other populations and settings is Psychoeducation Responsive to Families (PERF), a multifamily group model developed by the authors and colleagues. PERF was originally developed for families of people affected by schizophrenia.4 During the past 2 decades, however, the PERF approach and model have been adapted for use with various populations facing a range of different problems.

Key Elements of Family Psychoeducation

To fully understand research translation efforts, it is essential to specify the key elements of the model to be translated. Conceptually, these elements include the purpose of the intervention; structural elements, eg, length of intervention; standardization; participants; and projected outcomes.

The purpose of family psychoeducation is to provide state-of-the-art education, problem-solving, coping activities, and psychosocial support.5,6 Psychoeducation, as used here, is not conceptualized as “therapy,” because the need for personal growth and change among individual group participants is indeterminate.

For the educational component, the structure of family psychoeducation requires standardization of the educational materials in a consistent format with manualization of group procedures. Further, family psychoeducation, as opposed to education-focused models, is not a brief model. Although recommendations for optimal duration vary, and briefer models have been tested, a determined number of group sessions across a number of months (generally 6 months or more) is considered an essential part of the family psychoeducation model.7

The family psychoeducation model, as defined here, includes both professional and family participants. Although a clear case can be made for the effectiveness and importance of consumer-led family groups,8 the belief here is that the interaction between professionals and families provides additional opportunities for problem-solving and support. Previously, the authors labeled this approach “family as partner” with representation of the need for responsiveness to family needs in the PERF model name (PsychoEducation Responsive to Families).4,9 This led to the conceptualization of the term “family member” to include any individual who self-identifies or is identified by the person with illness as “family” for purposes of participation in a multiple family psychoeducation group.4

Specific models exist for various family members (eg, parents or siblings); some models exclude the person with illness, and others include non-kinship relations as part of the family construct along with the person with illness (PERF is one of these).6 Finally, family psychoeducation focuses on achieving positive outcomes for both the family members and the persons with mental illness.6 Conceptually, the rationale for this focus is that improvement in outcomes (eg, burden of illness, knowledge of treatment options) for family members leads to improvement in illness-related outcomes for the identified family member (eg, improved medication adherence, decreased hospitalization).

Translational Research in Mental Health

Although there are many ways to conceptualize translational research, we used the model described by Brekke and colleagues10 that consists of two distinct phases. In the first phase, knowledge generated during laboratory and preclinical research is applied to the facilitation of clinical trials and research conducted with human subjects. The focus of this translation phase consists of advancing knowledge from basic science to efficacy of clinical interventions. All in all, the overarching goal is to develop, and then test, evidence-based interventions in community-based mental health settings.10,11

The second phase of translation focuses on ways to improve the adoption of evidence-based practices in the community. This phase involves two types of knowledge transfer: dissemination; and implementation of evidence-based practices. Dissemination includes distributing necessary information about evidence-based interventions to practitioners, such as through written guidelines.12,13 Good examples of dissemination research results are the Substance Abuse and Mental Health Services Administration (SAMHSA) toolkit for implementing mental health practices, and the recommendations from the Family Forum meetings conducted by the VA.3

Implementation uses various strategies to either apply a new evidence-based mental health intervention or modify an existing evidence-based mental health intervention for a specific setting.12 In contrast to dissemination, implementation of evidence-based mental health practices in clinical settings requires a different kind of research, one that examines the process of translating interventions into usual-care settings.

Also known as the “transportation of interventions,” the process involves the adoption, adaptation, and infusion of evidence-based practices into usual-care sites. Implementation research may also involve generalizing an already-transported intervention across different types of community agencies.12 The translation of PERF for use in a variety of community settings is an example of this type of intervention.

Development of PERF

PERF for Families

Development of the original PERF model4 began in the early 1990s by members of this team as an adaptation of the well-established McFarlane model of multifamily psychoeducation groups for schizophrenia.14 The “family-responsive” format emerged from the PERF philosophy that families (including the member with illness) are capable partners who can contribute their own preferences and desires in the pursuit of their treatment needs.

In the development of PERF, therefore, each specific family psychoeducation group determined its own curriculum topics. The resulting curriculum was then created through a set protocol, drawing educational material from an existing manual for previously requested topics, or creating new material for novel topics using established procedures. This structured yet flexible, participant-driven approach to family participation is a core distinction of PERF, and one that remains consistent across all of its applications.

An adaptation of PERF was in the group-inclusion criteria. At the time of the original multiple family psychoeducation groups conducted by North and colleagues, family psychoeducation was primarily focused on family management of schizophrenia, which was subsequently expanded to include bipolar disorder and other psychotic and severe mood disorders. Based on this experience, inclusion criteria were further expanded, and PERF opened participation to families with an identified member with any serious psychiatric disorder, eg, severe obsessive-compulsive disorder, panic disorder, and borderline personality disorder, all participating together in diverse family psychoeducation groups.

As opposed to efficacy research, PERF did not exclude families if the identified member with illness had a psychiatric comorbidity, most commonly a substance use disorder. No specific interpersonal relationship was required for inclusion of “family” participating along with the identified member with the illness. If the person with illness did not have an identified family member, but wanted to participate, the individual identified by the person with illness as a proxy family member or caregiver was included regardless. Thus, broad inclusion criteria can be considered a hallmark of the PERF model adaptations.

After initially establishing the PERF model in a hospital setting, PERF was pilot tested in a small clinical trial conducted in partnership with the St. Louis chapter of the National Alliance for Mental Illness (NAMI)9 in preparation for testing in a large, NIMH-funded randomized clinical trial also conducted in partnership with NAMI. Family psychoeducation participants for this research were recruited through a 1-day community workshop15 and then randomized to PERF or a scripted consumer-led multi-family group intervention organized by NAMI. Table 1 presents the key elements of the original PERF model and each of the subsequent PERF applications.

PERF Applications for Specific Patient Populations

Table 1. PERF Applications for Specific Patient Populations

PERF groups in the original model met twice monthly for 12 months (24 total sessions). Groups met for 90 minutes and were co-facilitated by a medically based mental health professional (psychiatrist or psychiatric nurse) and a non-medical mental health professional (psychologist, social worker, or licensed counselor). Multifamily group sessions followed a set structure, with separate attention to didactic education, problem solving and coping, and “brainstorming” discussions around problems identified by group members. All subsequent PERF models used this session structure.

The didactic materials for each topic selected by individual groups were created following a set protocol, and the resulting content was collected to create a manualized curriculum. During the initial development of PERF, members of this research team were involved in the testing of another psychoeducation program, entitled Schizophrenia Treatment and Education Programs (STEPS).16 STEPS is an intensive family psychoeducation program specifically designed as an intervention for schizophrenia in a private-sector practice.

Uniquely initiated from an inpatient setting, STEPS extends the capabilities of other psychoeducation models limited to outpatients so that the intervention begins during acute inpatient care, when the severity of illness and treatment intensity are maximal and the potential for benefit is large. Similar to the PERF initiative, the STEPS initiative was among the first studies to translate the efficacy of psychoeducation demonstrated in academic environments into effectiveness in more general mental health care settings.16

PERF for Families with a Seriously Emotionally Disturbed Child (C-PERF)

The first application from the original PERF model was focused on family psychoeducation for children with severe emotional and behavioral disturbance. The initial interest in children emerged as a number of families with children who had mental disorders attended 1-day workshops held as part of the development of the original PERF intervention model. Although some of the material presented in the initial workshops was pertinent to these families, evaluation surveys found these families to be seeking further information and support around issues specific to raising children with psychiatric disorders. Based on these results, two workshops aimed specifically for families with younger children and teenagers were conducted. Feedback and data from these workshops specific to families with school-aged children led to the development of the C-PERF application.

The C-PERF intervention was originally targeted for families with a child in middle school. This was because of a lack of this type service for children this age identified by workshop participants, which was confirmed through a literature review and meetings with the local Special School District. In contrast to the original PERF model, inclusion criteria were based on the child’s assessment within the school district and subsequent eligibility for special services. In response, students were referred by their school-based social worker. Family psychoeducation groups were located within the school the students attended.17

As part of the translation process, the C-PERF modification was tailored to the school cycle. Groups were scheduled after school hours. The basic group structure and methods for creating the family-responsive curriculum were maintained, but the youth with “emotional or behavioral disturbance” (the term used by the school system at the time of the group) did not themselves participate in the session. After an initial family psychoeducation group was held in a neutral setting (a local university), the final C-PERF application was specified. Groups were co-facilitated by a school social worker and the school nurse. A second room in the same area of the school was provided for all the children of the participating families, and unstructured recreational activities were provided by facilitators professionally trained in behavioral management (generally, advanced MSW students from a local university). Protocols for emergency situations were created to support these facilitators.18

PERF for Families of Runaway Homeless Youth (RHY-PERF)

Another application of PERF was to runaway homeless youth. Developed in part within an ongoing research relationship with a local agency serving runaway homeless and other at-risk youth, this adaptation was similar in structure to our C-PERF adaptation. The groups included the same number of sessions; group structure and curriculum development were identical; groups (held at the local shelter) were facilitated by professional staff working for the agency; and families were recruited while the identified youth member of the family was housed in the short-term shelter or immediately after departure from the shelter. Because the RHY-PERF youth were generally older than those in the C-PERF application, they were invited to attend the PERF group sessions with their families. Development efforts for RHY-PERF were funded through a NIDA R-21 (development of promising intervention) mechanism.

What is most notable about the RHY-PERF model was its lack of success. Despite multiple recruitment efforts and strategies, including a 1-day workshop for families (that was sparsely attended), enlistment was so unsuccessful that no groups met beyond an initial handful of sessions. Eventually, a series of focus groups was conducted with family members, service staff, and identified youth. From these focus groups, an understanding emerged as to what went wrong in the proposed RHY-PERF model. It was learned that although previous investigation19 indicated that the shelter youth were descriptively very similar to those in the C-PERF adaptation, conceptually they constituted two separate subgroups, neither of which could benefit from PERF. In one subgroup, the identified youth were engaged with their families and were likely to return home without significant agency support.

In the other subgroup, the identified youth remained unengaged with their families, who reported a variety of issues being faced by the parents serving as barriers to the youth returning home. Youth in the first subgroup did not need RHY-PERF, and youth in the second subgroup did not have the family resources to engage in a long-term group commitment. The focus groups informed the investigative team that neither subgroup was appropriate for this intervention; therefore, the RHY-PERF application was abandoned.

PERF for Families Affected by Hepatitis C (HCV-PERF)

HCV-PERF is currently nearing completion of its recruitment; numerous HCV-PERF groups have been completed. HCV-PERF emerged out the extended experience of members of the investigative team with HCV patients. A longstanding member of this research team, Barry A. Hong, PhD, is chief of clinical psychology in a major medical school’s department of psychiatry and also provides consultation for the medical center’s HCV service; he was also an early collaborator in the development of the original PERF model.

HCV-PERF participants were recruited by clinic personnel or research staff in infectious disease and liver clinics providing HCV treatment. The HCV-PERF groups were conducted in Dallas and St. Louis, in hospital or clinic setting from which HCV patients and their family members were recruited at major universities, a VA hospital, and community practices.

Although the duration of psychoeducation groups was shortened to 12 sessions over 6 months, the HCV-PERF psychoeducation group structure and curriculum is consistent with the original model, and methods for creating the curriculum and providing educational materials are the same.

Groups are co-facilitated by two clinical specialists (a mental health professional and a clinician represented by a nurse or physician specializing in liver disease and/or infectious disease). Analysis of the results of HCV-PERF is currently under way, involving data from more than 300 participants in the program.

PERF for Military Veterans with SMI (VA-PERF)

The other current trial returns to the same population in the initial PERF, families with a member with severe mental illness. This application of PERF departs from the original PERF model in two ways. First, the trial is set within a Veterans Administration Medical Center (VAMC). Second, although the inclusion criteria remain basically the same as in the initial PERF trial, the identified member with mental illness must be a military veteran and eligible for services at the specific VAMC. Group structure and curriculum are based on the initial PERF, with the exception that the groups last only 6 months. The groups are co-facilitated by two professional clinical specialists based within the VAMC. Recruitment is through clinician referral and qualifying diagnosis determined through chart review. Group recruitment has been extremely slow to this point and is facing recruitment issues similar to RHY-PERF.

Translational Activities

Conceptualizing the PERF translation consists of three sets of activities: establishing the need for the applications, identifying and creating community partnerships, and adapting and modifying the model. For PERF applications to date, these activities generally took place in two identifiable phases. The first phase consisted of activities necessary for creating the new PERF model. These included establishing the need for the translation and developing community partnerships for applications of the model. Although these two sets of activities are conceptually separate, in terms of the process of translation, they often occurred simultaneously, and often in a single action meeting both needs. Table 2 first presents actions conducted before creating the translation model, followed by delineation of the features of the model emerging from the translation efforts.

PERF Models and Translational Activities

Table 2. PERF Models and Translational Activities

Need for Translation

Activities establishing the need for specific translations generally involved collection of formal data. The first method of collecting basic information used in establishing the initial PERF and C-PERF adaptations was through collection of “problem lists” during 1-day workshops with family members identified with psychiatric illness, including both adults and children, some of which were also attended by local mental health professionals.

At the start of each workshop, all participants were asked to list problems that family members, identified family members with illness, and professionals faced in coping with mental illness and/or helping people cope with mental illness.20 Results from the initial problem list analysis were used to establish the need for family input into creating group curriculum. Although the “family-responsive” format had previously been implemented in the initial PERF pilots, the findings of this analysis affirmed the nature of the adaptation and led in part to its incorporation across all subsequent adaptations. A similar analysis comparing problems identified by families with adult and with child members with mental illness established the need for a separate group for families with children,21 leading to the adaptation distinguishing C-PERF from PERF.

The second data-driven approach was through conducting focus groups to help understand the reasons for the failure of the RHY-PERF application and to aid in the specification and recruitment methods of HCV-PERF. The secondary advantage of using a formalized data collection method is the potential “added value” of insights gained from data analysis.

Community Partnerships

Establishing community partnerships does not simply imply unidirectional communications from expert researchers to the community partner. Rather, it is better understood as a series of feedback loops in which academic and community partnerships are established, with communication flow proceeding in both directions. An assumption throughout the developmental process and implementation process for the various PERF applications was that community partners had organizational needs and important insights in to the populations that they served. In many of the PERF applications, group facilitators were professional staff associated with the agencies (C-PERF, RHY-PERF, HCV-PERF, VA-PERF). Key to establishing and maintaining relationships with community partners was recognition of a shared commitment to the relevant population. Particular attention was paid to including clinicians and other staff working directly with the population in the developmental process. Beyond providing important pathways for referrals, staff enthusiasm for the approach and goals of the various PERF applications proved essential to ongoing agency commitment.

In addition to the focus on partnering with staff in the development and implementation of the PERF applications, the researchers maintained a commitment to the organization. In the original PERF, as well as in its other applications, various members of the research team had longstanding relationships with the host agencies.

Adaption and Modification of the Model

A final data collection method used in establishing the potential for a specific application was through pilot activities. In the PERF and C-PERF translations, preliminary groups were held to further specify the model and to develop materials.9,18 In the C-PERF development process, this led to a substantial change in the model. The initial C-PERF group was conducted outside the school setting (by Dr. McClendon). While this group was successful, feedback from family members included integrating the group more closely to the school calendar, which led to changes in the second iteration of C-PERF.

Involvement of the research team in conducting and supervising the groups both in the pilot process and during the clinical trials proved valuable repeatedly throughout the various translational efforts. In each of the applications (with the exception of RHY-PERF), involvement of research staff, all of whom have clinical experience in the conducting of groups, led to significant insights into the strengths and limitations of the applications. For PERF, the initial specification was based on the researchers’ experience in conducting the group. Similarly, C-PERF facilitation contributed to the significant changes in the model described above. Research staff co-facilitated HCV-PERF groups.

Discussion

Our team’s successes and failures have led to some specific lessons learned regarding the translation and implementation of family psychoeducation into community settings. These lessons fit conceptually into the factors limiting translational efforts presented by August and colleagues.22

Participant and Situational Constraints

It is necessary to clearly establish the need for the translation in advance of developing the specific model. This is aptly illustrated in comparing the success of the C-PERF application with the resounding failure of the RHY-PERF application. In C-PERF, the preliminary data collected through the problem lists clearly pointed to a need to create a model for families with children with serious disorders that is separate from those with adults with mental illness.

Further, in developing the child-focused 1-day workshops, the team was able to access directly the experience of the family members and establish their willingness to attend interventions. In contrast, although the runaway homeless population superficially had many similarities to the C-PERF population, collecting data directly from the families to establish the need and potential applicability of PERF to their situation would have identified the significant differences between the two populations in the ability of families to participate that would have alerted the investigators to application issues that might have been addressed.

Practitioner Attributes

In terms of practitioner attributes, our experience is that inclusion of practitioners in all aspects of the development process is key to successful translation. This is true for providing insight into the model, as well as for understanding the context in which the proposed implementation will be staffed. In developing PERF implementations, it is clear that attending to factors that increase or decrease staff enthusiasm is important to ongoing referrals of study participants and staffing the groups. This parallels concerns around sustainability in the more general translation literature,23 as well as the ongoing ability of agency staff to maintain acceptable levels of intervention fidelity.12

A good example of this is in the current VA-PERF trial, for which a key part of recruiting staff and maintaining enthusiasm through a long Institutional Review Process (IRB) process was the agreement by the participating VAMC that the groups would count as part of clinicians’ workload productivity, and that the supervision provided as part of the PERF process would “count” toward licensure and training requirements (and similar incentives were also offered in the initial PERF model).

In terms of development, the researchers’ previous experience conducting PERF groups directly led to significant modifications and changes to the initial PERF model, and subsequent experience of researchers in conducting C-PERF and HCV-PERF led to important insights in specifying the final models. Ongoing clinical supervision conducted by research staff led to insights into issues encountered by the practitioners and helped point out specific responses to common challenges.

Intervention Structure

We have found that a successful translation effort of PERF into “real-world” settings requires flexibility within models. Although there has been considerable attention to issues surrounding intervention fidelity in the translational literature,12,23 the experience of the researchers here is that key to the sustainability of the model is the ability for the practitioners to take some ownership of the model.

For example, within the structure of the individual group session, brainstorming has been separated into two sessions, one focused on describing problems faced by families and a subsequent one developing solutions to specific problems drawing on group member experiences.4 In situations where this separation has been lost, the single combined brainstorming has frequently devolved into a complaint session. Thus, in maintaining the model, adhering to the session structure has been identified as necessary to maximize likelihood of success.

Clinician input contributes to clinician enthusiasm; participation helps recruit families and the success of the individual groups.

Organizational Culture

In terms of organizational culture, the need for communication between the researcher and community partners is similar to the focus throughout the process on inter-organizational communication in the Aaron and colleagues23 model, and is found throughout the translational literature. Collaboration between community partners on incorporating the organization’s goals into planning the PERF process also parallels the translational research.23,24

Research in Community Settings

In conducting research in community settings, it is essential to ensure that the community partners understand the proposed methods. While threats to research are well understood, community partners are not researchers and do not necessarily work according to the methodological constraints of clinical trials. In working with community partners, it is necessary first to explain the choices, but more importantly, to be truly collaborative in respecting the partner’s concerns. For example, in the VA-PERF project, rather than randomizing to two different treatments, following the expressed concerns of the agency, the randomization was “treatment now” versus “treatment later.”

It is also important to consider that translation trials often requires quite complex Human Subjects protocols, which requires close work with committees that often have little or no experience in these types of applications. Issues related to IRBs have, at times, brought studies to a halt. This is particularly true when research teams have to interact with multiple IRBs, such as cooperating VAs and universities that have substantially different requirements.

Inclusion at all levels (families in their groups and translation development, staff and agency management in development and implementation) in the treatment process through education and support represents a promising direction for interventions in chronic health conditions. A model in which family and multidisciplinary professional team members are partners in the development and implementation process has broad applicability in the movement toward integrated health care for management of chronic mental health and medical conditions.

References

  1. Lehman AF, Steinwachs DM. At issue: Translating research into practice: The schizophrenia patient outcomes research team (PORT) treatment recommendations. Schizophrenia Bull. 1998;24(1):1–10. doi:10.1093/oxfordjournals.schbul.a033302 [CrossRef]
  2. Dadich A. Communicating evidence-based mental health care to service users. Aust J Psychol. 2009;61(4):199–210. doi:10.1080/00049530802579499 [CrossRef]
  3. Cohen AN, Glynn SM, Murray-Swank A, et al. The Family Forum: Directions for implementation of family psychoeducation for severe mental illness. Psychiatr Serv. 2008;59:40–48. doi:10.1176/appi.ps.59.1.40 [CrossRef]
  4. North CS, Pollio DE, Sachar B, Hong B, Isenberg K, Bufe G. The family as caregiver for schizophrenia: a group psychoeducation model. Am J Orthopsychiatry. 1998;68(1):39–47. doi:10.1037/h0080268 [CrossRef]
  5. McFarlane WR. Multifamily Groups in the Treatment of Severe Psychiatric Disorders. New York: Guilford; 2002.
  6. Lefley HP. Family Psychoeducation for Serious Mental Illness. Oxford: Oxford University Press; 2009. doi:10.1093/acprof:oso/9780195340495.001.0001 [CrossRef]
  7. Solomon P. Moving from psychoeducation to family education for adults with serious mental illness. Psychiatr Serv. 1996; 47:1364–1370.
  8. Pickett-Schenk SA, Cook JA, Steigman P, Lippincott R, Bennet C, Grey DD. Psychological well-being and relationship outcomes in a randomized study of family-led education. Arch Gen Psychiatry. 2006;63:1043–1050. doi:10.1001/archpsyc.63.9.1043 [CrossRef]
  9. Pollio DE, North CS, Osborne V. Family-responsive psychoeducation groups for families with an adult member with mental illness: pilot results. Commun Mental Health J. 2002;38(5):413–421. doi:10.1023/A:1019812512926 [CrossRef]
  10. Brekke JS, Ell K, Palinkas LA: Translational science at the National Institute of Mental Health: can social work take its rightful place?Res Social Work Practice. 2007;17(1):123–133. doi:10.1177/1049731506293693 [CrossRef]
  11. Palinkas LA, Schoenwald SK, Hoagwood K, Landsverk J, Chorpita BF, Weisz JR. An ethnographic study of implementation of evidence-based treatments in child mental health: first steps. Psychiatr Serv. 2008;59(7):738–737. doi:10.1176/appi.ps.59.7.738 [CrossRef]
  12. Drake RE, Goldman HH, Leff HS, et al. Implementing evidence-based practices in routine mental health service settings. Psychiatr Serv. 2001;52(2):179–182. doi:10.1176/appi.ps.52.2.179 [CrossRef]
  13. Mueser KT, Torrey WC, Lynde D, et al. Implementing evidence-based practices for people with severe mental illness. Behav Modif. 2003;27:387–341. doi:10.1177/0145445503027003007 [CrossRef]
  14. McFarlane WR, Lukens E, Link B, et al. Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry. 1995;52:679–687. doi:10.1001/archpsyc.1995.03950200069016 [CrossRef]
  15. Pollio DE, North CS, Reid DL, McCabe MM, McClendon JR. Family skills workshop: living with severe mental illness-what families and friends must know: an evaluation of a one-day psychoeducation workshop. Social Work. 2006;51:31–38. doi:10.1093/sw/51.1.31 [CrossRef]
  16. Vickar GM, North CS, Downs D, Marshall D. A randomized controlled trial of a private-sector inpatient-initiated psychoeducation program for schizophrenia. Psychiatr Serv. 2009;60:117–120. doi:10.1176/appi.ps.60.1.117 [CrossRef]
  17. Pollio DE, McClendon JB, North CS, Reid DL, Jonson-Reid M. The promise of school-based multifamily psychoeducation groups for families with a child coping with severe emotional or behavioral disorders. Children Schools. 2005;27(2):111–116. doi:10.1093/cs/27.2.111 [CrossRef]
  18. McClendon J, Pollio DE, North CS, Reid D, Jonson-Reid M. School-based groups for parents of children with emotional and behavioral disorders: pilot results. Families Society. 2007;88(1):124–129.
  19. Pollio DE, Thompson ST, Tobias L, Reid D, Spitznagel E. Longitudinal outcomes for runaway homeless youth shelter users. J Youth Adolesc. 2006; 35(5):852–859. doi:10.1007/s10964-006-9098-6 [CrossRef]
  20. Pollio DE, North CS, Foster DE. Content and curriculum in multifamily psychoeducation. Psychiat Serv. 1998;49(6):816–822.
  21. Pollio DE, North CS, Reid D, Eyrich KM, McClendon J. Differences in problems faced by families coping with a child or an adult member with mental illness. J Social Service Res. 2006;32(4):83–98. doi:10.1300/J079v32n04_05 [CrossRef]
  22. August GJ, Winters KC, Realmuto GM, et al. Moving evidence-based drug abuse prevention programs from basic science to practice: bridging the efficacy-effectiveness interface. Substance Use Misuse. 2004;39(10–12):2017–2053. doi:10.1081/JA-200033240 [CrossRef]
  23. Aaron GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health. 2011;38:4–23. doi:10.1007/s10488-010-0327-7 [CrossRef]
  24. McFarlane WR, Lukens E, Link B, et al. Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry. 1995;52:679–687. doi:10.1001/archpsyc.1995.03950200069016 [CrossRef]

PERF Applications for Specific Patient Populations

Model Population of focus Duration/number of sessions Primary location Inclusion criteria for identified family member Primary recruitment mechanism Primary intended outcomes
PERF Identified family member with serious mental illness 12 months/24 sessions NAMI offices Diagnosis of schizophrenia, bipolar disorder, schizoaffective disorder 1-day community workshop

Family: increased coping, knowledge, quality of life, social support; decreased burden.

Member: decreased hospitalization, increased medication adherence, increased quality of life.

C-PERF Middle school student with serious emotional or behavioral disturbance School semester/12 sessions Middle school attended by child Emotional or behavioral disorder identified by state agency Referral by school social worker

Family: increased knowledge, decreased burden, improved family/child relationship.

RHY-PERF Runaway and homeless youth 6 months/12 sessions Youth shelter Stay in brief shelter Self-referral by family or child at youth shelter

Family: improved parenting skills and knowledge, well-being, decreased burden.

Youth: improved functioning, housing stability.

HCV-PERF Patients with HCV 12 months/24 sessions HCV clinic HCV diagnosis Referral from hospital-based HCV clinics

Member: increased readiness for treatment, greater treatment adherence, improved medical outcomes.

VA-PERF Military veterans with serious mental illness 6 months/12 sessions VA medical center Any diagnosis from medical record including psychotic disorder Referral by VA social worker

Family: improved coping, increased knowledge, decreased burden.

Member: increased knowledge, medication adherence, and quality of life.

PERF Models and Translational Activities

Model Recruitment source Activities prior to model specification Adapting and modifying the model
PERF NAMI-sponsored workshop

Development of initial model.

Creation of community partnership with NAMI prior to developing research.

Development of 1-day workshop to recruit motivated families.

Use of problem lists to examine issues faced by families.

Development of a “family-as-partner” approach.

Identified family member with any psychiatric disorder.

Broad definition of “family”.

Family (including identified member) chooses curriculum topics.

Community recruitment by volunteer population.

Co-facilitated by psychiatrist and other mental health professional (psychologist, therapist, social worker).

C-PERF Special school district

Determined need by examining difference in problems reported by families with an adult member with mental illness and families with children with emotional and behavioral disorders attending a 1-day workshop.

Development of community partnership with school district.

Meetings with staff and administrators at school to determine need and structure of model.

Family member not identified through diagnosis.

Parents/caretakers identified as “family”.

Model shortened (12 sessions).

Activity group provided for adolescent and other children.

New curriculum topics.

Recruited by case managers.

Co-facilitated by psychiatrist and other mental health professional (including school-based professionals).

RHY-PERF Shelter and transitional housing services

Long-standing existing research relationship with community partner by research team member (Pollio), including previous successful projects.

Multiple assessments and meetings to determine agency needs and model translation.

Focus groups with family members, youth, and staff.

Family member identified through child’s admission to shelter.

Parents/caretakers identified as “family”.

Model shortened (12 sessions).

New curriculum topics.

Co-facilitated by mental health personnel from participant agency.

HCV-PERF Staff in HCV clinic of major hospital

Partnership with medical faculty with unique expertise in HCV to determine need and structure of model.

Involvement of available research staff in each setting.

Focus groups of HCV patients.

HCV patient enlisted through clinic; HCV diagnosis validated in clinical records.

Broad definition of “family”.

Inclusion of patients with no accompanying family member.

Same length as original PERF.

New curriculum topics.

Co-facilitated by HCV specialist and mental health professional.

VA-PERF Veterans Affairs medical center programs

Partnership with research and clinical staff at community VA.

Multiple meetings to determine needs and model translation.

Appointment of PI to VA staff to provide ongoing supervision.

Project developed as part of academic/VA partnership initiative at local level.

Inclusion of Vet-PERF as part of clinicians’ service requirements.

Veteran referred through social work personnel and staff of other research projects; psychiatric diagnosis verified in medical records.

Inclusion of veterans with no accompanying family member

Shorter length (12 sessions).

New curriculum topics.

Co-facilitated by social work staff at VA.


Authors

David E. Pollio, PhD, is Hill Crest Foundation Endowed Chair in Mental Health Research, School of Social Work, University of Alabama. Carol S. North, MD, MPE, is Nancy and Ray L. Hunt Chair in Crisis Psychiatry and Professor in the Departments of Psychiatry and Surgery, Division of Emergency Medicine, Section on Homeland Security University of Texas Southwestern Medical Center; and Director of the Program in Trauma and Disaster at the VA North Texas Health Care System. Ashley M. Hudson, MSW, is a Research and Teaching Assistant, School of Social Work, University of Alabama. Barry A. Hong, PhD, is Professor of Psychiatry, Department of Psychiatry, Washington University. Victoria A. Osborne, PhD, is Assistant Professor, School of Social Work, University of Missouri. Jennifer B. McClendon, PhD, is Assistant Professor, School of Social Work, Adelphi University.

Disclosure: This research was funded in part by grants R21 DA015341 and R24 MH059217 and a grant from the VA to Dr. Pollio, and grant R01-015201 to Dr. North. The authors wish to thank National Alliance for the Mentally Ill of St Louis, Youth-In-Need, Special School District of St. Louis, and the Dallas and Tuscaloosa VAMCs, as well as their numerous other community collaborators without whom these projects could not have been completed. The authors also wish to thank their numerous research collaborators over the years. Points of view in this document are those of the authors and do not necessarily represent the official position of the Department of Veterans Affairs or the US Government.

Address correspondence to: David E. Pollio, PhD, School of Social Work, 225 Little Hall, Campus Box, University of Alabama, Tuscaloosa, AL 35487. email: depollio@sw.ua.edu

10.3928/00485713-20120606-06

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