Updates and Five-year Evaluation of the S.A.F.E. Program: A Family Psychoeducational Program for Serious Mental Illness
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- Sherman, M.D. Community Ment Health J (2006) 42: 213. doi:10.1007/s10597-005-9018-3
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This brief report reviews recent updates to the S.A.F.E. Program, a family psychoeducational intervention for serious mental illness created in the Veterans Affairs (VA) system. The improvements and significant content additions to the curriculum are outlined. Further, positive five-year program evaluation data are described, including high levels of participant retention and satisfaction. Program attendance is positively correlated with understanding of mental illness, awareness of VA resources, and ability to engage in self-care activities—and inversely correlated with caregiver distress. This data lays the groundwork for a randomized clinical trial and raises questions about the necessity of diagnostic-specific family programming.
Keywordsserious mental illnessfamily psychoeducationveteranPTSDfamily therapy
The Support and Family Education (S.A.F.E.) Program: Mental Health Facts for Families (Sherman, 2003) is a psychoeducational family intervention created and began at the Oklahoma City Veterans Affairs (VA) Medical Center in March, 1999. Distinct from other family interventions in its creation specifically for the VA system, its inclusion of posttraumatic stress disorder (PTSD), and its applicability to a wide range of mental illnesses, it has been adopted (in part or in its entirety) by a range of private and public institutions across the county. It has also been described as an exemplary model of family intervention in Robert P. Liberman M.D.’s forthcoming book, Rehabilitation of the Mentally Disabled: A Manual for Practitioners. Given the large number of armed services members currently returning from Iraq and Afghanistan who are dealing with mental illness, and PTSD specifically (Hogue et al., 2004), reaching out to and supporting these families will be vital. This brief report summarizes the updates added to the manual’s second edition and reviews encouraging 5-year program evaluation data.
Despite the numerous mandates to provide family services for clients living with serious mental illness (Lehman et al., 2004), a small minority of families receives services (Dixon et al., 1999). A recent survey of 124 VA medical centers found that 22% of the hospitals provide or refer families to family services, and the large majority of these services are peer-led community-based support groups provided through the National Alliance for the Mentally Ill (NAMI) (McCutcheon, 2003). Hence, considerable effort will be required to shift the paradigm of mental health service delivery in order to divert the funds and staffing necessary to provide the needed services. Exploration of the level of readiness to implement family programming in four key stakeholders (clients, family members, clinicians and administrators) will be essential (Sherman & Carothers, 2005).
The S.A.F.E. Program was initially released in 1999 as a 14-session professional curriculum of workshops for people who care about someone with a serious mental illness. Each session has a didactic component (e.g., “What causes mental illness”), group discussion, and a period for questions posed to a psychiatrist. Ninety-minute workshops are presented monthly on an on-going basis, so families can join the program at any time. The workshops are facilitated by a psychologist and a psychiatrist. Three-year evaluation data revealed high program retention and satisfaction. Workshop attendance was also positively correlated with the family member’s understanding of mental illness, awareness of VA resources, and improvements in the caregiver’s ability to perform self-care (Sherman, 2003).
The entire S.A.F.E. manual has been available for free online since December 2000 (http://www.w3.ouhsc.edu/safeprogram). To date, the site has received over 60,000 hits from all 50 American states and over 80 countries worldwide. Also, program manuals have been distributed to over 300 public and private sites throughout the world.
The S.A.F.E. Program was updated in 2003, involving revision of some of the original sessions and the addition of four new workshops. More specifically, newly released epidemiological data, resources, and group exercises were added to the sessions on depression, schizophrenia and PTSD. The four new sessions address issues that had previously received insufficient attention.
The first new session, “Common family reactions to mental illness,” normalizes various family reactions and discusses how the family experience of mental illness is qualitatively different from that of serious physical illness. Two stage models of caregiver responses are outlined, including data from a recent qualitative analysis of the caregiving experience (Karp, 2001). Several video clips are suggested and helpful reminders about self-care are reviewed.
Second, “Problem-solving skills for families” addresses common challenges faced by families and outlines specific styles of coping with problems. A six-step problem-solving strategy is presented and rehearsed in session, with encouragement for families to implement the process in their relationships. Third, “Creating a low-stress environment and minimizing crises” reviews the importance of maintaining a low-key household and provides tips on managing stress effectively. Families are instructed about numerous red flags that may signify a potential crisis, as well as specific behavioral and communication strategies to implement during stressful times. The group engages in role-plays to practice some of these skills. Families are assisted in creating a personalized crisis plan.
Finally, “Coping with the stigma surrounding mental illness” begins with an experiential exercise to sensitize families to the experience of stigma. A brief review of stigma’s history and the role of labeling in stigma provide the context for a group discussion about the participants’ family experience of stigma. Effective means of coping with stigma are explored, including empowering families to focus on the control they do have (by creating a decisional balance regarding disclosure), surround themselves with supportive people, retain hope, and consider advocacy efforts.
Five-year participation and evaluation data
In the first 5 years of the program (March 1999–February 2004), 170 family members attended at least one workshop. Almost 80% of participants were females, which is logical given the predominantly male veteran population in the VA healthcare system. Almost one-third of the participants were in their 50s, while approximately 23% were in their 40s and 16% in their 60s. Notably, more young family members have joined the program in the past few years, likely due to the recent increase in young veterans joining the VA system. Almost 45% of the participants were wives; other family members included mothers (12%), adult children (11%), husbands (6%), and siblings (5%). Strikingly, the clients’ primary diagnoses varied widely, including almost 40% with P.T.S.D., followed by ∼20% with major depression, 17% schizophrenia and 15% with bipolar disorder. Over 40% of the caregivers’ clients had a fairly recent diagnosis (within past 10 years), and over half of the caregivers lived with their loved one. A large majority of the caregivers were White (88.2%), followed by African American (7.1%), Hispanic (2.4%) and American Indian (2.4%).
Of caregivers who attended more than one workshop, the average number of sessions attended was 6.3±2.4 sessions. Given that sessions are held monthly, the ability to retain participants across this time period is noteworthy. The program appeals to caregivers dealing with a variety of mental illnesses, evidenced by the descriptive data reflecting similarities in the percentages of caregivers who attended more than one session (66% of caregivers whose loved one had depression attended more than one session, 55% for schizophrenia, 53% for PTSD, and 41% for bipolar disorder, respectively). Similarly, the SAFE Program reaches a variety of caregivers; when comparing the percentages of different relatives who attended more than one session, similarities emerged (59% of wives attended more than one session, 50% of parents, and 45% of adult children, respectively). The average number of participants per session was 9.5±4.1, although this figure has increased over the five-year period. The most well attended sessions (in decreasing order of popularity) addressed PTSD, self-care, practical coping tips, and anger/violence. Importantly, content from two of these sessions (dealing with PTSD and anger) are not specifically targeted in most family intervention programs.
Participant satisfaction is assessed at every workshop via four 5-point Likert scale items and several qualitative items. The overall mean score was 18.2±2.4 out of a possible 20 (N=518). Family members also indicated that receiving handouts, talking to peers, and asking doctors questions were especially helpful.
Finally, participants complete background information forms at every session, and several Pearson correlations were examined. The number of sessions attended was significantly correlated with awareness of VA resources (r=.44, p<.0001, N=118), level of caregiver distress (r=−.31, p<.001, N=118), understanding of mental illness (r=.27, p<.005, N=118) and ability to engage in self-care (r=.20, p<.03, N=118). (Note: The participants who were also VA employees did not complete the monthly assessments; therefore, these data are only the non-employee caregivers).
Examining only the non-employee caregivers who attended more than one session, two significant correlations also emerged. The number of sessions attended was significantly correlated with ability to engage in self-care (r=.40, p<.005, N=70) and level of caregiver distress (r=−.39, p<.006, N=70).
Anecdotally, caregivers report great pleasure at the availability of the S.A.F.E. Program, oftentimes expressing a wish that it had been available many years ago. Participants frequently bring friends and family members to sessions; they also provide helpful suggestions to the facilitator as to other means of publicizing the program. Caregivers encourage their veterans to publicize the program to other veterans in their therapy groups. A few participants have visited VA hospitals across the country during personal vacations and shared about the S.A.F.E. Program. Some caregivers have taken on advocacy roles, such as by participating in the hospital’s mental health consumer council to improve care at the facility. Some participants describe the program as having saved their families/marriages, and they express much gratitude for the information and support provided in the workshops.
Participants also indicate that the knowledge and confidence they gain in the S.A.F.E. Program helps them, their loved ones, and family relationships. Some participants use the workshop handouts as a means of reviewing the didactic material and instigating constructive discussions with their loved ones. Other caregivers develop friendships with one another that provide socialization and support beyond the confines of the monthly sessions. Regular participants warmly welcome and support the new members; they also encourage the new caregivers to attend sessions consistently by drawing upon the 12-step motto of “keep coming back!”
In addition, mental health professionals at other sites who offer the S.A.F.E. Program find it user-friendly, well organized, concise yet thorough in its content coverage, and encouraging of group discussion. Therapists have described their experience with the S.A.F.E. Program as very rewarding personally and professionally, as participating caregivers have felt neglected by the system and are grateful for the information and support. Professionals from a wide range of settings are offering the program (e.g., public and private hospitals and clinics, managed care corporations, centers for abused/neglected youth, churches), each modifying it to meet their specific needs.
This five-year data reveals that S.A.F.E. Program attendance is associated with several positive outcomes. Plans are currently underway for the next more rigorous evaluation of the S.A.F.E. Program’s effectiveness, namely a randomized clinical trial. It would be useful for future research to examine the reasons that some participants choose to not attend the S.A.F.E. Program regularly, and to explore if other interventions may better suit these families’ needs. Also, the extent to which the camaraderie that quickly develops in the VA-based S.A.F.E. Program would build as quickly in the private sector is uncertain; perhaps the shared pride and bonds among veterans’ families facilitate the group cohesion and mutual support that so readily emerge. Although the generalizability of the current findings are limited by the quasi-experimental design and the reliance on self-report measures, the findings are hopeful and lay important groundwork for subsequent research.
In light of the variety of families that participate and the simultaneous high customer satisfaction, it’s unclear that family intervention programs need to be diagnostic-specific. Although the majority of other curricula focus on a specific diagnostic category (Sherman, 2004), the S.A.F.E. Program appeals to a broader audience. This ability to meet the needs of a variety of families is especially important in light of our returning soldiers and our challenge with treatment engagement of families. Experience with the S.A.F.E. Program demonstrates that the commonality of need across diverse caregivers may outweigh their needs for specific diagnostic information (that can be obtained via bibliotherapy and individual sessions with a case manager).